Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba …€¦ · · 2017-12-01Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP)

Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP)

Special Meeting Monday, December 4, 2017, 2:00 p.m. Gold Coast Health Plan, 711 East Daily Drive, Community Room, Camarillo, CA 93010

AMENDED AGENDA

CALL TO ORDER

PLEDGE OF ALLEGIANCE

ROLL CALL

PUBLIC COMMENT

The public has the opportunity to address Ventura County Medi-Cal Managed Care Commission (VCMMCC) doing business as Gold Coast Health Plan (GCHP) on the agenda. Persons wishing to address VCMMCC should complete and submit a Speaker Card.

Persons wishing to address VCMMCC are limited to three (3) minutes. Comments regarding items not on the agenda must be within the subject matter jurisdiction of the Commission.

PRESENTATIONS

1. AmericasHealth Plan (AHP) Pilot Proposal

CONSENT CALENDAR (ROLL CALL VOTE REQUIRED)

2. Approval of Ventura County Medi-Cal Managed Care Commission MeetingRegular Minutes of October 23, 2017

Staff: Tracy Oehler, Clerk of the Board

RECOMMENDATION: Approve the minutes.

3. Approval of the 2018 Ventura County Medi-Cal Managed Care CommissionMeeting Calendar

Staff: Tracy Oehler, Clerk of the Board

RECOMMENDATION: Approve the 2018 Commission meeting calendar.

Page 1 of 153

4. Accept and File the September 2017 Year to Date Financials

Staff: Lyndon Turner, Interim Chief Financial Officer

RECOMMENDATION: Accept and file September 2017 Fiscal Year to Date Financials.

5. Approval of Contract Extension and Additional Funding for Emagined Security,Managed Security Services – Service Orders No. 1 and 4

Staff: Melissa Scrymgeour, Chief Administrative Officer

RECOMMENDATION: Authorize the Chief Executive Officer to execute (1) anamendment to Emagined Security Service Order No. 1 to extend the term from February1, 2018 to January 31, 2020 for on-demand information security engineering andarchitecture services at a not-to-exceed amount of $152,000 for such period; and (2) anew Service Order No. 4 for additional managed security operations center (SOC)services for the period of January 1, 2018 to December 31, 2018, with a 12-monthrenewal option and a not-to-exceed amount of $178,750 for the two-year period. Thetotal amount for the two Service Orders is $330,750.

FORMAL ACTION ITEMS

6. Quality Improvement Committee 2017 Third Quarter Report

Staff: Nancy Wharfield, M.D., Chief Medical Officer

RECOMMENDATION: Accept and file the Quality Improvement Committee 2017 ThirdQuarter Report.

7. State of California Department of Health Care Services Contracts AmendmentA25 for Capitation Rates for Fiscal Year 2015-16

Staff: Dale Villani, Chief Executive Officer

RECOMMENDATION: Approve and authorize the Chief Executive Officer to executeDepartment of Health Care Services Amendment A25.

8. State of California Department of Health Care Services Contracts AmendmentA26 for Capitation Rates for Fiscal Year 2016-17

Staff: Dale Villani, Chief Executive Officer

RECOMMENDATION: Approve and authorize the Chief Executive Officer to executeDepartment of Health Care Services Amendment A26.

Page 2 of 153

9. State of California Department of Health Care Services Contracts Amendment

A27 for Capitation Rates for Fiscal Year 2014-15 Staff: Dale Villani, Chief Executive Officer RECOMMENDATION: Approve and authorize the Chief Executive Officer to execute

Department of Health Care Services Amendment A27. 10. Approval of Consulting Services Agreement and Statement of Work with TBJ

Consulting for Interim Chief Diversity Officer Services Staff: Joseph Ortiz, General Counsel’s Office RECOMMENDATION: Approve the Consulting Services Agreement and Statement of

Work with TBJ Consulting for Interim Chief Diversity Officer services. 11. Approval of Office Sublease Agreement for 711 East Daily Drive, Suites 105 and

107, Camarillo, California Staff: Ruth Watson, Chief Operating Officer RECOMMENDATION: Authorize and direct the Chief Executive Officer to execute an

agreement with NAI Capital to represent Gold Coast Health Plan as the Plan’s exclusive agent for sublease of Suites 105 and 107 at 711 East Daily Drive, Camarillo, California.

12. Approval to Begin Process to Secure Additional Medi-Cal funds through an

Intergovernmental Transfer (IGT) Staff: Dale Villani, Chief Executive Officer RECOMMENDATION: Authorize and direct the Chief Executive to provide the

Department of Health Care Services with a proposal, including information from the funding entity, to the State of California.

REPORTS 13. Chief Executive Officer (CEO) Update RECOMMENDATION: Accept and file the report. 14. Compliance Update RECOMMENDATION: Accept and file the report.

Page 3 of 153

15. Chief Operating Officer (COO) Update RECOMMENDATION: Accept and file the report. 16. Internal Audit Updates: AB85 Auto-Assignment; Human Resources and Payroll;

and Accounts Payable RECOMMENDATION: Accept and file the report 17. Chief Medical Officer (CMO) Update RECOMMENDATION: Accept and file the report. 18. Human Resources Compensation Plan RECOMMENDATION: Accept and file the report. 19. Chief Diversity Officer (CDO) Update RECOMMENDATION: Accept and file the report. CLOSED SESSION 20. CONFERENCE WITH LEGAL COUNSEL – ANTICIPATED LITIGATION Significant exposure to litigation pursuant to paragraph (2) of subdivision (d) of Section

54956.9: Four Cases 21. CONFERENCE WITH LEGAL COUNSEL – ANTICIPATION LITIGATION Initiation of litigation pursuant to paragraph (4) of subdivision (d) of Section 54956.9:

One Case 22. PUBLIC EMPLOYEE PERFORMANCE EVALUATION Title: Chief Executive Officer 23. CONFERENCE WITH LABOR NEGOTIATORS Agency designated representatives: Scott Campbell, General Counsel and Gold Coast

Health Plan Commissioners Unrepresented employee: Chief Executive Officer COMMENTS FROM COMMISSIONERS

Page 4 of 153

ADJOURNMENT

Unless otherwise determined by the Commission, the next regular meeting will be held on January 22, 2018, at Gold Coast Health Plan at 711 E. Daily Drive, Suite 106, Community Room, Camarillo, CA 93010. _________________________________________________________________________________________ Administrative Reports relating to this agenda are available at 711 East Daily Drive, Suite #106, Camarillo, California, during normal business hours and on http://goldcoasthealthplan.org. Materials related to an agenda item submitted to the Commission after distribution of the agenda packet are available for public review during normal business hours at the office of the Clerk of the Board.

In compliance with the Americans with Disabilities Act, if you need assistance to participate in this meeting, please contact (805) 437-5509. Notification for accommodation must be made by the Monday prior to the meeting by 3 p.m. to enable the Clerk of the Board to make reasonable arrangements for accessibility to this meeting.

Page 5 of 153

October 23, 2017 1

Ventura County Medi-Cal Managed Care Commission (VCMMCC)

dba Gold Coast Health Plan (GCHP)

October 23, 2017 Regular Meeting Minutes CALL TO ORDER Commissioner Darren Lee called the meeting to order at 2:00 p.m. in the Community Room located at Gold Coast Health Plan, 711 E. Daily Drive, Camarillo, California. PLEDGE OF ALLEGIANCE Commissioner Lee led the Pledge of Allegiance. ROLL CALL Present: Commissioners Antonio Alatorre, Shawn Atin, Lanyard Dial, M.D., Narcisa

Egan, Laura Espinosa (arrived at 2:03 p.m.), Peter Foy (arrived at 2:03 p.m.), Michelle Laba, M.D., Darren Lee, Gagan Pawar, M.D., Catherine Rodriguez, and Jennifer Swenson.

Absent: None. PUBLIC COMMENT None. The Commission unanimously agreed to pull Agenda Item Nos. 3 through 7 for individual consideration. CONSENT CALENDAR (ROLL CALL VOTE REQUIRED) 1. Approval of Ventura County Medi-Cal Managed Care Commission Meeting

Special Minutes of August 30, 2017 Staff: Tracy Oehler, Clerk of the Board RECOMMENDATION: Approve the minutes. 2. Approval of Ventura County Medi-Cal Managed Care Commission Meeting

Regular Minutes of September 25, 2017 Staff: Tracy Oehler, Clerk of the Board RECOMMENDATION: Approve the minutes. Commissioner Swenson moved to approve the recommendations. Commissioner Atin seconded.

AGENDA ITEM NO. 2

Page 6 of 153Back to Agenda

October 23, 2017 2

AYES: Commissioners Alatorre, Atin, Dial, Egan, Laba, Lee, Pawar, Rodriguez,

and Swenson. NOES: None. ABSTAIN: None. ABSENT: Commissioners Foy and Espinosa. Commissioner Lee declared the motion carried. Commissioners Foy and Espinosa arrived at 2:03 p.m. The Commission unanimously agreed to hear Agenda Item No. 15 – Pharmacy Benefits Manager (PBM) Update. REPORTS

15. Pharmacy Benefits Manager (PBM) Update RECOMMENDATION: Accept and file the report. There were seven public speakers. April Miles, a representative for OMAC Pharmacy, expressed concern over the

PBM reimbursement rates. Kent Miles, a representative for Home Care Pharmacy, expressed concern over

the PBM reimbursement rates. Joe Hoffman, a representative for Oxnard Drug, expressed concern over the PBM

reimbursement rates. Jeffrey T. White expressed concern over the PBM reimbursement rates. Ali Farandish expressed concern over the PBM reimbursement rates. Rajindar Rai expressed concern over the PBM reimbursement rates. Robert Andonian, a representative for Farmacia Estrella, expressed concern over

the PBM reimbursement rates.

Anne Freese, PharmD, Director of Pharmacy, gave an update on the PBM implementation. The agreement with Kaiser has not been executed, but members are not being impacted. The 340B program coding issue is still outstanding. The Commission expressed concern over whom the responsible party is for the 340B program coding costs as well as when the coding will be completed.


October 23, 2017 3

Dr. Freese introduced OptumRx representative Denise Olson, Vice President of Provider Relations. Ms. Olson introduced OptumRx representative Josh Van Ginkle, Director of Network Contracting. Mr. Van Ginkle stated OptumRx has meet with 20 pharmacies over the past two and a half weeks and gave an overview of the maximum allowable cost (MAC) review process. Clarification was made on how the reviews were for the individual drugs and not for each claim submitted. A discussion followed between the Commissioners and staff regarding dispensing fees, costs, and the definition of terms. The overpayment of approximately $1.8 million to 48 pharmacies, due to an error in June of 2017 and was corrected in July of 2017, was also discussed. The overpayment will need to be recouped and OptumRx will be working with the impacted pharmacies over the next couple of months.

Mr. Campbell announced Closed Session Item No. 16 Report Involving Trade Secret – Pharmacy Benefits Manager Rates and under the Ralph M. Brown Act, the earliest the rates may be disclosed is three years; Closed Session Item No. 17 – Anticipated Litigation involving the letter received from the pharmacies; and Closed Session Item No. 18 – Existing Litigation involving the Script Care lawsuit. CLOSED SESSION The Commission adjourned to Closed Session at 3:12 p.m. 16. REPORT INVOLVING TRADE SECRET Discussion will concern: Pharmacy Benefits Manager Rates Estimated date of disclosure: In three years, at the earliest. 17. CONFERENCE WITH LEGAL COUNSEL – ANTICIPATED LITIGATION

Significant exposure to litigation pursuant to paragraph (2) of subdivision (d) of Section 54956.9: One Case

18. CONFERENCE WITH LEGAL COUNSEL – EXISTING LITIGATION Name of Case: Script Care v. Ventura County Medi-Cal Managed Care

Commission dba Gold Coast Health Plan, Case No. 56-2017-00492349 CV-WM-VTA

The Regular Meeting reconvened at 4:45 p.m. Mr. Campbell stated there was no reportable action.


October 23, 2017 4

OPEN SESSION REPORTS

15. Pharmacy Benefits Manager (PBM) Update RECOMMENDATION: Accept and file the report. Commissioner Lee stated Gold Coast Health Plan has had to pay penalties due to overpayment of pharmacy benefits and the overall strategy of the Request for Proposals was to reduce costs in order to avoid being penalized by the State of California. Two-thirds of the reduction came from administrative costs and one-third of the reduction was passed onto the pharmacies. After the review of specific data, some pharmacies received more on brand, some pharmacies received more on generic, some pharmacies’ reimbursements were relatively the same, and some pharmacies received less in both categories. The Commission expects OptumRx to continue to work with the pharmacy services administrative organizations (PSAOs) and Dr. Freese regarding these issues and to communicate proactively. Lastly, since the MACs were not properly implemented, there was an overpayment of approximately $1.8 million to the pharmacies, which will be recouped by the end of this calendar year. Commissioner Dial moved to approve the recommendation. Commissioner Atin seconded. AYES: Commissioners Alatorre, Atin, Dial, Egan, Espinosa, Foy, Laba, Lee,

Pawar, Rodriguez, and Swenson. NOES: None. ABSTAIN: None. ABSENT: None. Commissioner Lee declared the motion carried. The Commission unanimously agreed to hear Agenda Item Nos. 3 through 5 together. CONSENT CALENDAR 3. Approval of Contract Extension and Additional Funding with Foothills

Consulting Group for Information Technology Consulting and Staff Augmentation Services – Service Order 01 IT Senior Business Systems Analyst

Staff: Melissa Scrymgeour, Chief Administrative Officer RECOMMENDATION: Approve a contract extension to June 30, 2018, with

Foothills Consulting Group for information technology consulting and staff augmentation services for $105,000 with a not to exceed amount of $200,000.


October 23, 2017 5

4. Approval of Additional Funding for the Foothills Consulting Group Contract for Information Technology Consulting and Staff Augmentation Services – Service Order 02 IT Senior Business Systems Analyst

Staff: Melissa Scrymgeour, Chief Administrative Officer RECOMMENDATION: Approve additional funding for the Foothills Consulting

Group Contract for information technology consulting and staff augmentation services for $135,000 with a not to exceed amount of $234,875.

5. Approval of Additional Funding for the Teksystems Contract for Information

Technology Consulting and Staff Augmentation Services – Service Order 05 IT Senior Developer

Staff: Melissa Scrymgeour, Chief Administrative Officer RECOMMENDATION: Approve additional funding for the Teksystems contract for

information technology consulting and staff augmentation services for $95,000 with a not to exceed amount of $194,500.

Melissa Scrymgeour, Chief Administrative Officer, stated the contracts extend the

funding for the resources necessary for the active portfolio projects. A discussion followed between the Commissioners and staff regarding the funding

is cost neutral as it is already in the budget and no additional funding is being requested.

Commissioner Rodriguez moved to approve the recommendation. Commissioner Egan seconded. AYES: Commissioners Atin, Egan, Foy, Laba, Lee, Pawar, Rodriguez, and

Swenson. NOES: Commissioners Alatorre and Espinosa. ABSTAIN: None. ABSENT: Commissioner Dial. Commissioner Lee declared the motion carried. 6. Approval of Additional Funding for the Current Contract Term and a Contract

Extension with Pacific Interpreters, Inc., for Telephone Interpreting and Video Remote Interpreting Services

Staff: Lupe González, Ph.D., M.P.H., Director of Health Education, Outreach,

Cultural and Linguistic Services


October 23, 2017 6

RECOMMENDATION: Approve additional funding for the current contract term and a twelve-month contract extension with Pacific Interpreters, Inc., for telephone interpreting and video remote interpreting services for $105,400 with a not to exceed amount of $202,400.

Commissioner Atin moved to approve the recommendation. Commissioner Rodriguez seconded. AYES: Commissioners Alatorre, Atin, Egan, Espinosa, Foy, Laba, Lee, Pawar,

Rodriguez, and Swenson. NOES: None. ABSTAIN: None. ABSENT: Commissioner Dial. Commissioner Lee declared the motion carried. 7. Approval of Additional Funding for the Dial Security Contract for Security

Controls Services Staff: Ruth Watson, Chief Operating Officer RECOMMENDATION: Approve additional funding for the Dial Security contract for

security controls services for $124,536 with a not to exceed amount of $575,000. The Commission directed staff to research cost effective options that can be

implemented once the current contract ends. Commissioner Atin moved to approve the recommendation. Commissioner Rodriguez seconded. AYES: Commissioners Alatorre, Atin, Egan, Espinosa, Foy, Laba, Lee, Pawar,

Rodriguez, and Swenson. NOES: None. ABSTAIN: None. ABSENT: Commissioner Dial. Commissioner Lee declared the motion carried.


October 23, 2017 7

FORMAL ACTION ITEMS 8. Request to Approve Resolution No. 2017-004 Adopting a Records

Management Program Policy and Records Retention Schedule

RECOMMENDATION: Approve Resolution No. 2017-004 adopting a Records Management Program Policy and Records Retention Schedule.

Commissioner Espinosa moved to approve the recommendation. Commissioner Egan seconded. AYES: Commissioners Alatorre, Atin, Egan, Espinosa, Foy, Laba, Lee, Pawar,

Rodriguez, and Swenson. NOES: None. ABSTAIN: None. ABSENT: Commissioner Dial. Commissioner Lee declared the motion carried. 9. Accept and Approve the Fiscal Year 2016-17 Audit Results RECOMMENDATION: Accept and approve the Fiscal Year 2016-17 Audit results. Lyndon Turner, Senior Financial Officer, stated Moss Adams, LLP had reported

the results of the audit at the earlier Audit Committee meeting today. Due to a scheduling conflict, Mr. Stelian Damu, the representative from Moss Adams, LLP, had to leave and would not be able to give the presentation.

Commissioner Rodriguez moved to approve the recommendation. Commissioner Alatorre seconded. AYES: Commissioners Alatorre, Atin, Egan, Espinosa, Foy, Laba, Lee, Pawar,

Rodriguez, and Swenson. NOES: None. ABSTAIN: None. ABSENT: Commissioner Dial. Commissioner Lee declared the motion carried. 10. August 2017 Year to Date Financials

RECOMMENDATION: Accept and file August 2017 Fiscal Year to Date Financials.


October 23, 2017 8

Mr. Turner stated the August fiscal year to date health care costs were $115.7

million or $9.5 million higher than budget and the medical loss ratio (MLR) was 100.4% versus 92.7% for budget. By October, the forecast for the tangible net equity (TNE) will be at 300%, which is below the required amount and will most likely result in a financial corrective action plan (CAP).

A discussion followed between the Commissioners and staff regarding correcting

the deficit. Commissioner Rodriguez directed staff to form a strategic plan committee. The Commission and staff agreed the Executive/Finance Committee could perform this assignment and would begin to address this issue at its next meeting in November.

Commissioner Lee moved to approve the recommendation. Commissioner Alatorre seconded. AYES: Commissioners Alatorre, Atin, Egan, Espinosa, Foy, Laba, Lee, Pawar,

Rodriguez, and Swenson. NOES: None. ABSTAIN: None. ABSENT: Commissioner Dial. Commissioner Lee declared the motion carried. REPORTS

11. Chief Executive Officer (CEO) Update RECOMMENDATION: Accept and file the report. Dale Villani, Chief Executive Officer, inquired if there were any questions regarding

the update. 12. Chief Operating Officer (COO) Update RECOMMENDATION: Accept and file the report. Ruth Watson, Chief Operating Officer, stated membership was down 456

members and staff has been meeting with AmericasHealth Plan (AHP) weekly. Commissioners Alatorre and Pawar recused themselves at 5:56 p.m. due to a potential conflict of interest. Ms. Watson stated AHP had proposed members would come from Clinicas Del

Camino Real at a rate of 1,250 per month for ten months. This exceeds the number of members the Commission had previously approved, which is 5,000 members.


October 23, 2017 9

Commissioner Swenson left the meeting at 5:59 p.m. Commissioners Alatorre and Pawar returned to the meeting at 6:00 p.m. 13. Chief Administrative Officer (CAO) Update RECOMMENDATION: Accept and file the report Melissa Scrymgeour, Chief Administrative Officer, reviewed the 2017-2020 GCHP

Strategic Plan. 14. Chief Medical Officer (CMO) Update RECOMMENDATION: Accept and file the report. Nancy Wharfield, M.D., Chief Medical Officer, stated staff is available for questions

on the health services and pharmacy updates. Commissioner Espinosa moved to approve the recommendation to accept and file Agenda Item Nos. 11 through 14. Commissioner Egan seconded. AYES: Commissioners Alatorre, Atin, Egan, Espinosa, Foy, Laba, Lee, Pawar, and

Rodriguez. NOES: None. ABSTAIN: None. ABSENT: Commissioners Dial and Swenson. Commissioner Lee declared the motion carried. Mr. Campbell announced the closed session agenda items as listed below. CLOSED SESSION The Commission adjourned to Closed Session at 6:05 p.m. 19. PUBLIC EMPLOYEE APPOINTMENT Title: Chief Diversity Officer

20. CONFERENCE WITH LABOR NEGOTIATORS Agency designated representatives: Scott Campbell, General Counsel and Gold

Coast Health Plan Commissioners Unrepresented employee: Chief Diversity Officer 21. PUBLIC EMPLOYEE PERFORMANCE EVALUATION Title: Chief Executive Officer


October 23, 2017 10

22. CONFERENCE WITH LABOR NEGOTIATORS Agency designated representatives: Scott Campbell, General Counsel and Gold

Coast Health Plan Commissioners Unrepresented employee: Chief Executive Officer

Commissioner Lee and Mr. Villani left closed session at 6:25 p.m. Mr. Campbell left closed session at 6:40 p.m. Mr. Campbell returned to closed session at 6:46 p.m. Mr. Campbell left closed session at 7:04 p.m. Commissioner Lee returned to closed session at 7:19 p.m. Mr. Campbell returned to closed session at 7:28 p.m. Mr. Villani returned to closed session at 7:30 p.m. OPEN SESSION The Regular Meeting reconvened at 7:47 p.m. Mr. Campbell stated there was no reportable action. COMMENTS FROM COMMISSIONERS None. ADJOURNMENT The meeting was adjourned at 7:48 p.m. APPROVED: ____________________________ Tracy J. Oehler, Clerk of the Board


AGENDA ITEM NO. 3

TO: Ventura County Medi-Cal Managed Care Commission FROM: Tracy J. Oehler, Clerk of the Board DATE: December 4, 2017 SUBJECT: Request to Approve the 2018 Ventura County Medi-Cal Managed Care

Commission Meeting Calendar SUMMARY: To establish the Commission meeting dates for the calendar year 2018. BACKGROUND: Meetings of legislative bodies are governed by California Government Code Section 54952 et seq. As such, the Ventura County Medi-Cal Managed Care Commission is required by law to establish regular meeting dates. Historically, these meeting dates have been the fourth Monday of each calendar month with the exception of December, as there is no meeting scheduled. However, each year the November Commission meeting conflicts with the Thanksgiving holiday resulting in its cancellation and the need to reschedule. Staff is proposing to eliminate the November meeting and to schedule the meeting for December 3, 2018. Additionally, the 2018 May meeting conflicts with the Memorial Day holiday and staff is proposing to move the meeting to May 21, 2018. Lastly, the annual Strategic Meeting has been added to the calendar for March 15, 2018. The attached 2018 Commission Meeting Calendar reflects the proposed changes. FISCAL IMPACT: N/A RECOMMENDATION: Approve the 2018 Commission Meeting Calendar. CONCURRENCE: N/A ATTACHMENT: Exhibit No. 1 – 2018 Commission Meeting Calendar


JanuaryS M T W T F S

1 2 3 4 5 67 8 9 10 11 12 1314 15 16 17 18 19 2021 22 23 24 25 26 2728 29 30 31

FebruaryS M T W T F S

1 2 3

4 5 6 7 8 9 1011 12 13 14 15 16 1718 19 20 21 22 23 2425 26 27 28

MarchS M T W T F S

1 2 34 5 6 7 8 9 10

11 12 13 14 15 16 1718 19 20 21 22 23 2425 26 27 28 29 30 31

AprilS M T W T F S1 2 3 4 5 6 78 9 10 11 12 13 14

15 16 17 18 19 20 2122 23 24 25 26 27 2829 30

MayS M T W T F S

1 2 3 4 56 7 8 9 10 11 1213 14 15 16 17 18 1920 21 22 23 24 25 2627 28 29 30 31

JuneS M T W T F S

1 23 4 5 6 7 8 910 11 12 13 14 15 1617 18 19 20 21 22 2324 25 26 27 28 29 30

JulyS M T W T F S1 2 3 4 5 6 78 9 10 11 12 13 14

15 16 17 18 19 20 2122 23 24 25 26 27 2829 30 31

AugustS M T W T F S

1 2 3 45 6 7 8 9 10 1112 13 14 15 16 17 1819 20 21 22 23 24 2526 27 28 29 30 31

2018 Ventura County Medi-Cal Managed Care Commission Meetings

711 E. Daily Drive, Community Room, Camarillo, CAMeeting time is at 2:00 p.m.

SeptemberS M T W T F S

12 3 4 5 6 7 89 10 11 12 13 14 15

16 17 18 19 20 21 2223 24 25 26 27 28 2930

OctoberS M T W T F S

1 2 3 4 5 67 8 9 10 11 12 13

14 15 16 17 18 19 2021 22 23 24 25 26 2728 29 30 31

NovemberS M T W T F S

1 2 34 5 6 7 8 9 10

11 12 13 14 15 16 1718 19 20 21 22 23 2425 26 27 28 29 30

DecemberS M T W T F S

12 3 4 5 6 7 89 10 11 12 13 14 15

16 17 18 19 20 21 2223 24 25 26 27 28 2930 31

Commission Meeting

Strategic Meeting

EXHIBIT NO. 1


AGENDA ITEM NO. 4

TO: Ventura County Medi-Cal Managed Care Commission FROM: Lyndon Turner, Interim Chief Financial Officer DATE: December 4, 2017 SUBJECT: September 2017 Fiscal Year to Date Financials SUMMARY: Staff is presenting the attached September 2017 fiscal year-to-date (FYTD) financial statements (unaudited) of Gold Coast Health Plan (“Plan”) for the Commission to accept and file. These financials were reviewed by the Executive/Finance Committee on November 17, 2017, where the Executive/Finance Committee recommended that the Commission accept and file these financials.

BACKGROUND/DISCUSSION: The staff has prepared the September 2017 FYTD financial package, including statements of financial position, statement of revenues, expenses and changes in net assets, and statement of cash flows. FISCAL IMPACT: Financial Highlights Overall Performance – For the three month period ended September 30, 2017, the Plan’s performance was a decrease in net assets of $6.5 million, which was $6.7 million higher than budget. Cost of health care was higher than budget by $9.2 million, which was driven by higher contracted rates and high-cost Inpatient claims. The medical loss ratio increased to 97.1 percent of revenue, which was 4.5 percent higher than the budget. Administrative savings were realized through lower than projected administrative expenses. The administrative cost ratio was 0.04 percent lower than budget.

Membership – September membership of 205,695 was 1,035 members higher than budget due higher than expected membership in the Adult Expansion category of aid.

Revenue – September FYTD net revenue was $173.3 million or $1.5 million higher than budget, On a PMPM basis, revenue was $2.80 PMPM above budget due to membership mix, with higher than expected Adult Expansion membership.


MCO Tax – MCO tax is a pre-determined liability in accordance with Senate Bill X2-2 passed in October 2016. The Plan’s MCO tax liability for FY 2018 is $89.3 million, accrued at a rate of approximately $7.4 million per month. The second quarterly installment of MCO tax for the fiscal year is scheduled for payment in January 2018.

Health Care Costs – September FYTD health care costs were $168.3 million or $9.2 million higher than budget. The medical loss ratio (MLR) was 97.1 percent versus 92.6 percent for budget.

Adult Expansion Population 85% Medical Loss Ratio – The Balance Sheet contains a $131.3 million reserve for return of potential Medi-Cal capitation revenue to the DHCS under the terms of the MLR contract language.

Administrative Expenses – For the fiscal year ended September 30, administrative costs were $12.4 million or $270,000 below budget. As a percentage of revenue, administrative costs (or ACR) were 7.1 percent versus 7.4 percent for budget.

Cash and Investments – At September 30, the Plan had $444.7 million in cash and short-term investments. The AE overpayment due to DHCS (related to incorrect rate payments and to achieve 85% MLR) totals $234.5 million. For the fiscal year ended September, the State has recouped a total of $45.8 million related to AE rate overpayment.

Investment Portfolio – At September 30, 2017, the value of the investments (all short term) was $250.9 million. The portfolio included Cal Trust $51.1 million; Ventura County Investment Pool $86.1 million; LAIF CA State $63.7 million; Bonds and Commercial Paper $50 million.

Classic Population

1/1/2014 - 6/30/2015 7/1/2015 - 6/30/2016 7/1/2016 - 6/30/2017 7/1/2016 - 9/30/17 7/1/2016 - 9/30/17

MLR Period 1 MLR Period 2 MLR Period 3 MLR Period 4

Total Revenue 361,237,234 293,173,426 268,060,238 66,534,242 106,730,775

Total Estimated Medical Expense 206,719,452 237,729,974 234,431,483 65,041,506 103,336,875

57.2% 81.1% 87.5% 97.8% 96.8%

Total MLR Reserve 118,168,494 13,101,452

Expansion Population


RECOMMENDATION: Staff requests that the Commission accept and file the September 2017 financial package. CONCURRENCE: November 17, 2017 ATTACHMENT: September 2017 Financial Package


FINANCIAL PACKAGE For the month ended September 30, 2017

TABLE OF CONTENTS

● Financial Overview

● Financial Performance Dashboard

● Cash and Operating Expense Requirements

APPENDIX

● Statement of Financial Positions

● YTD Statement of Revenues, Expenses and Changes in Net Assets

● Statement of Revenues, Expenses and Changes in Net Assets

● Statement of Cash Flows

● Membership

● Paid Claims and IBNP Composition


FY 2015-16 FY 2016-17 JUL 17 AUG 17 SEP 17 FYTD SEP 17BudgetFYTD

VarianceFav / (Unfav)

Member Months 2,413,136 2,485,202 203,077 205,002 205,695 613,774 614,409 (635)

Revenue 675,629,602 680,255,278 57,560,932 57,633,531 58,070,555 173,265,018 171,724,917 1,540,101 pmpm 279.98 273.72 283.44 281.14 282.31 282.29 279.50 2.80

Health Care Costs 583,149,780 645,931,276 57,605,616 58,083,191 52,607,136 168,295,943 159,064,086 (9,231,857) pmpm 241.66 259.91 283.66 283.33 255.75 274.20 258.89 (15.31) % of Revenue 86.3% 95.0% 100.1% 100.8% 90.6% 97.1% 92.6% -4.5%

Admin Exp 38,256,908 51,176,317 4,246,896 4,115,955 4,018,408 12,381,259 12,651,130 269,870 pmpm 15.85 20.59 20.91 20.08 19.54 20.17 20.59 0.42 % of Revenue 5.7% 7.5% 7.4% 7.1% 6.9% 7.1% 7.4% 0.2%

Non-Operating Revenue / (Expense) 1,790,949 3,254,139 302,433 282,279 328,847 913,559 228,967 684,593 pmpm 0.74 1.31 1.49 1.38 1.60 1.49 0.37 1.12 % of Revenue 0.3% 0.5% -0.5% -0.5% -0.6% -0.5% -0.1% -0.4%

Total Increase / (Decrease) in Unrestricted Net Assets 56,013,863 (13,598,175) (3,989,147) (4,283,336) 1,773,858 (6,498,625) 238,668 (6,737,293) pmpm 23.21 (5.47) (19.64) (20.89) 8.62 (10.59) 0.39 (10.98) % of Revenue 8.3% 2.0% -6.9% -7.4% 3.1% -3.8% 0.1% 3.9%

YTD 100% TNE 25,246,284 29,231,052 30,067,645 30,129,010 29,888,218 29,888,218 29,490,525 397,693 % TNE Required 100% 100% 100% 100% 100% 100% 100%Minimum Required TNE 25,246,284 29,231,052 30,067,645 30,129,010 29,888,218 29,888,218 29,490,525 397,693 GCHP TNE 155,959,127 142,360,951 138,371,804 134,088,469 135,862,326 135,862,326 142,599,619 (6,737,292) TNE Excess / (Deficiency) 130,712,843 113,129,900 108,304,160 103,959,459 105,974,109 105,974,109 113,109,094 (7,134,985) % of Required TNE level 618% 487% 460% 445% 455% 455% 484%

Description

AUDITED Budget ComparisonAUDITED FY 2017-18


FINANCIAL PERFORMANCE DASHBOARDFOR MONTH ENDING SEPTEMBER 30, 2017

Adult / Family

SPDDual

TLIC

Adult Expansion

0

25,000

50,000

75,000

100,000

125,000

150,000

175,000

200,000

225,000

Mem

bers

hip

Membership and GrowthMembership by Aid Category by Quarter

45%

24%

44%

25%

43%

26%

5%

17%

5%

16%

5%

16%

9%16%

9%14%

10% 15%

14%

3%

14%5%

15%5%

26%

40%27%

39%28%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MM FY 2015-16 Rev FY 2015-16 MM FY 2016-17 Rev FY 2016-17 MM September 17 Rev September 17

Adult / Family SPD Dual TLIC AE

Membership Mix and Revenue Impact

Op Gain8.7%

Op Gain7.9%

Op Loss-1.7%

Op Loss-3.8%

ACR 5.6% ACR 6.1%ACR 7.3% ACR 7.1%

MLR85.8%

MLR86.3% MLR

94.9%MLR

97.1%

-20%

0%

20%

40%

60%

80%

100%

FY 2014-15 * FY 2015-16 FY 2016-17 FYTD SEP 17

Note: FY 14 and FY 15 differs from Budget Presentation due to Auditors' Adjustments. Medical Loss Ratio (MLR), Administrative Cost Ratio (ACR)

Key Performance Indicators

FY 2014-15 * FY 2015-16 FY 2016-17 FYTD SEP2017

Operating Gain/(Loss) $51,610 $56,014 $(13,598) $(6,499)TNE $99,945 $155,959 $142,361 $135,862Required TNE $22,557 $25,246 $29,231 $29,888500% of Required TNE $112,783 $126,231 $146,155 $149,441

Operating Gain/(Loss)

TNE

Required TNE

500% of Required TNE

-$50,000

$0

$50,000

$100,000

$150,000

$200,000

Stat

ed in

Tho

usan

ds

Operating Gain and Tangible Net Equity

* FY 14 and FY 15 differs from Budget Presentation due to audit adjustments. FY 16 updated for Operating Gain and TNE Only TNE excludes LOC ($7.2M)


50

100

150

200

250

300

350

400

450

500

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

$ M

illi

on

s

Cash & Operating Expense Requirements

Cash/Invst Cash/Invst (Less State Liab) Liquid Reserve Target

GOLD COAST HEALTH PLANFY 2017 - 18

Assumes payback to DHCS for AE rate overpayment and MLR (85%) capitation to be completed by April 2018.


For the month ended September 30, 2017

APPENDIX

● Statement of Financial Position

● YTD Statement of Revenues, Expenses and Changes in Net Assets

● Statement of Revenues, Expenses and Changes in Net Assets

● Statement of Cash Flows

● Membership

● Paid Claims and IBNP Composition


09/30/17 08/31/17 07/31/17

ASSETS

Current Assets:Total Cash and Cash Equivalents $ 193,796,041 $ 203,943,722 $ 167,132,712 Total Short-Term Investments 250,896,509 250,730,805 269,555,019Medi-Cal Receivable 92,245,791 94,731,725 122,618,874Interest Receivable 516,998 459,850 518,205Provider Receivable 557,467 667,563 705,630Other Receivables 1,500,000 1,500,000 1,500,000Total Accounts Receivable 94,820,256 97,359,139 125,342,709

Total Prepaid Accounts 1,614,382 1,893,643 1,794,254Total Other Current Assets 135,560 135,560 135,560Total Current Assets 541,262,749 554,062,870 563,960,255

Total Fixed Assets 2,216,537 2,260,874 2,305,131

Total Assets 543,479,286$ 556,323,744$ 566,265,386$

LIABILITIES & NET ASSETS

Current Liabilities:Incurred But Not Reported 56,345,708$ 52,073,578$ 53,141,812$ Claims Payable 23,839,533 28,239,908 18,179,523Capitation Payable 57,160,872 57,125,863 57,354,194DHCS - Reserve for Capitation Recoup 131,269,946 131,269,946 131,269,946Accounts Payable 2,268,304 9,034,195 16,052,879Accrued ACS 1,688,638 1,707,424 1,691,408Accrued Expenses 112,140,057 127,422,461 142,483,948Accrued Premium Tax 20,492,764 13,047,415 5,602,074Accrued Payroll Expense 1,390,368 1,293,442 1,096,483Total Current Liabilities 406,596,190 421,214,233 426,872,267

Long-Term Liabilities:Other Long-term Liability-Deferred Rent 1,020,770 1,021,042 1,021,315Total Long-Term Liabilities 1,020,770 1,021,042 1,021,315

Total Liabilities 407,616,960 422,235,276 427,893,582

Net Assets:Beginning Net Assets 142,360,951 142,360,951 142,360,951Total Increase / (Decrease in Unrestricted Net Assets) (6,498,625) (8,272,483) (3,989,147)

Total Net Assets 135,862,326 134,088,469 138,371,804

Total Liabilities & Net Assets 543,479,286$ 556,323,744$ 566,265,386$

STATEMENT OF FINANCIAL POSITION


Variance Actual Budget Fav / (Unfav)

Membership (includes retro members) 613,774 614,409 (635)

RevenuePremium 195,601,048$ 195,356,739$ 244,309$ MCO Premium Tax (22,336,030) (23,631,822) 1,295,792

Total Net Premium 173,265,018 171,724,917 1,540,101

Total Revenue 173,265,018 171,724,917 1,540,101

Medical Expenses:Capitation (PCP, Specialty, Kaiser, NEMT & Vision) 15,555,073 16,265,533 710,460

FFS Claims Expenses:Inpatient 31,724,766 32,891,286 1,166,520LTC / SNF 30,001,315 28,983,033 (1,018,283)Outpatient 13,817,390 12,972,481 (844,909)Laboratory and Radiology 1,105,378 687,313 (418,065)Emergency Room 8,193,191 6,286,912 (1,906,279)Physician Specialty 13,604,726 12,819,163 (785,563)Primary Care Physician 4,520,326 3,637,760 (882,566)Home & Community Based Services 3,640,622 4,551,571 910,949Applied Behavior Analysis Services 1,983,107 1,173,235 (809,872)Mental Health Services 1,571,783 2,340,316 768,533Pharmacy 35,345,808 27,993,075 (7,352,733)Other Medical Professional 848,154 1,200,646 352,492Other Medical Care 6,240 0 (6,240)Other Fee For Service 2,574,219 1,988,281 (585,938)Transportation 569,572 367,585 (201,987)

Total Claims 149,506,595 137,892,657 (11,613,938)

Medical & Care Management Expense 2,824,510 3,560,340 735,830Reinsurance 756,685 1,345,556 588,871Claims Recoveries (346,920) 0 346,920

Sub-total 3,234,274 4,905,896 1,671,621

Total Cost of Health Care 168,295,943 159,064,086 (9,231,857)Contribution Margin 4,969,075 12,660,831 (7,691,756)

General & Administrative Expenses:Salaries, Wages & Employee Benefits 5,631,544 5,993,882 362,338Training, Conference & Travel 66,921 172,774 105,853Outside Services 6,476,271 6,919,913 443,642Professional Services 1,081,801 895,500 (186,301)Occupancy, Supplies, Insurance & Others 1,650,977 2,229,400 578,423ARCH/Community Grants 298,254 0 (298,254)Care Management Credit (2,824,510) (3,560,340) (735,830)

Total G & A Expenses 12,381,259 12,651,130 269,870

Total Operating Gain / (Loss) (7,412,184)$ 9,701$ (7,421,885)$

Non OperatingRevenues - Interest 913,559 228,967 684,593

Total Non-Operating 913,559 228,967 684,593

Total Increase / (Decrease) in Unrestricted Net Assets (6,498,625)$ 238,668$ (6,737,293)$

Net Assets, Beginning of Year 142,360,951Net Assets, End of Current Period 135,862,326

SEPTEMBER 2017 Year-To-Date

STATEMENT OF REVENUES, EXPENSES AND CHANGES IN NET ASSETSFOR THREE MONTHS ENDED SEPTEMBER 30, 2017


Jun 17 Jul 17 Aug 17 Variance Actual Budget Fav / (Unfav)

Membership (includes retro members) 203,990 203,077 205,002 205,695 204,660 1,035

Revenue:Premium 62,406,054$ 65,006,273$ 65,078,872$ 65,515,904$ 65,051,905$ 463,998$ MCO Premium Tax (7,333,552) (7,445,341) (7,445,341) (7,445,348) (7,871,774) 426,426

Total Net Premium 55,072,502 57,560,932 57,633,531 58,070,555 57,180,131 890,424

Total Revenue 55,072,502 57,560,932 57,633,531 58,070,555 57,180,131 890,424

Medical Expenses:Capitation (PCP, Specialty, Kaiser, NEMT & Vision) 5,296,649 5,196,768 5,162,964 5,195,341 5,412,808 217,467

FFS Claims Expenses:Inpatient 8,603,936 11,930,937 11,586,395 8,207,433 10,947,673 2,740,240LTC / SNF 10,552,442 10,602,658 10,114,354 9,284,303 9,649,015 364,712Outpatient 3,812,264 3,455,473 5,607,078 4,754,839 4,319,221 (435,617)Laboratory and Radiology 211,239 432,458 350,157 322,764 228,858 (93,905)Physician ACA 1202 370,381 0 0 0 0 0Emergency Room 2,211,124 2,077,878 3,020,035 3,095,278 2,092,463 (1,002,815)Physician Specialty 4,741,892 4,524,338 4,665,076 4,415,312 4,268,892 (146,421)Primary Care Physician 1,708,898 1,402,259 1,302,571 1,815,495 1,211,346 (604,149)Home & Community Based Services 1,475,139 1,078,625 1,072,894 1,489,103 1,520,222 31,119Applied Behavior Analysis Services 684,387 627,661 757,729 597,717 390,562 (207,155)Mental Health Services 697,153 664,607 426,848 480,327 778,856 298,529Pharmacy 12,698,077 13,244,829 11,428,152 10,672,826 9,314,312 (1,358,514)Other Medical Professional 368,748 287,126 294,355 266,673 399,900 133,227Other Medical Care 0 0 6,240 0 0 0Other Fee For Service 842,709 801,567 960,938 811,715 662,332 (149,383)Transportation 391,072 147,303 247,980 174,290 122,281 (52,008)

Total Claims 49,369,463 51,277,719 51,840,803 46,388,074 45,905,932 (482,141)

Medical & Care Management Expense 1,113,973 862,769 1,015,943 945,798 1,136,347 190,549Reinsurance 252,147 251,985 251,278 253,422 448,205 194,783Claims Recoveries (672,140) 16,376 (187,798) (175,499) 0 175,499

Sub-total 693,979 1,131,130 1,079,423 1,023,721 1,584,552 560,831

Total Cost of Health Care 55,360,092 57,605,616 58,083,191 52,607,136 52,903,293 296,157Contribution Margin (287,590) (44,684) (449,660) 5,463,419 4,276,839 1,186,580

General & Administrative Expenses:Salaries, Wages & Employee Benefits 1,949,388 1,745,912 1,986,761 1,898,872 1,967,351 68,479 Training, Conference & Travel 26,061 22,722 20,631 23,568 59,075 35,507 Outside Services 2,276,567 2,099,910 2,197,098 2,179,263 2,304,920 125,657 Professional Services 587,108 354,196 391,965 335,641 281,058 (54,582)Occupancy, Supplies, Insurance & Others 858,173 588,671 535,444 526,862 603,332 76,469 ARCH/Community Grants 1,202,990 298,254 0 0 0 0 Care Management Credit (1,113,973) (862,769) (1,015,943) (945,798) (1,136,347) (190,549)

Total G & A Expenses 5,786,313 4,246,896 4,115,955 4,018,408 4,079,389 60,981

Total Operating Gain / (Loss) (6,073,903) (4,291,580) (4,565,615) 1,445,011 197,449 1,247,562

Non Operating:Revenues - Interest 323,968 302,433 282,279 328,847 76,240 252,607

Total Non-Operating 323,968 302,433 282,279 328,847 76,240 252,607Total Increase / (Decrease) in Unrestricted Net Assets (5,749,936) (3,989,147) (4,283,336) 1,773,858 273,689 1,500,168

Full Time Employees 180 184 4

STATEMENT OF REVENUES, EXPENSES AND CHANGES IN NET ASSETS

Current MonthFY 2016-17 FY 2017-18 Monthly TrendSEPTEMBER 2017


STATEMENT OF CASH FLOWS July 17 Aug 17 Sept 17 FYTD 17-18Cash Flows Provided By Operating Activities

Net Income (Loss) (3,989,147) (4,283,336) 1,773,858 (6,498,625) Adjustments to reconciled net income to net cash provided by operating activities

Depreciation on fixed assets 44,685 44,257 44,337 133,279 Amortization of discounts and premium (28,951) (26,201) (22,098) (77,250)

Changes in Operating Assets and LiabilitesAccounts Receivable 2,361,682 27,983,570 2,538,883 32,884,134 Prepaid Expenses 1,704,743 (99,389) 279,261 1,884,615 Accounts Payable (2,245,306) (21,867,467) (21,970,428) (46,083,201) Claims Payable (4,662,380) 9,832,054 (4,365,366) 804,307 MCO Tax liablity (13,573,650) 7,445,341 7,445,348 1,317,039 IBNR (224,535) (1,068,234) 4,272,130 2,979,361

Net Cash Provided by Operating Activities (20,612,860) 17,960,595 (10,004,074) (12,656,340)

Cash Flow Provided By Investing ActivitiesProceeds from Restricted Cash & Other AssetsProceeds from Investments 50,000,000 19,000,000 - 69,000,000 Proceeds for Sales of Property, Plant and EquipmentPayments for Restricted Cash and Other AssetsPurchase of Investments (40,068,401) (149,585) (143,607) (40,361,592) Purchase of Property and Equipment (7,750) (7,750)

Net Cash (Used In) Provided by Investing Activities 9,923,849 18,850,415 (143,607) 28,630,658

Cash Flow Provided By Financing ActivitiesNone - - - -

Net Cash Used In Financing Activities - - - -

Increase/(Decrease) in Cash and Cash Equivalents (10,689,011) 36,811,010 (10,147,681) 15,974,318 Cash and Cash Equivalents, Beginning of Period 177,821,723 167,132,712 203,943,722 177,821,723 Cash and Cash Equivalents, End of Period 167,132,712 203,943,722 193,796,041 193,796,041


GOLD COAST HEALTH PLAN

OCT 16 NOV 16 DEC 16 JAN 17 FEB 17 MAR 17 APR 17 MAY 17 JUN 17 JUL 17 AUG 17 SEP 17 Budget -Sep 17

Total 209,381 208,890 208,148 206,664 206,970 205,829 205,106 204,140 203,990 203,077 205,002 205,695 204,660FAMILY 92,364 91,653 91,071 90,477 90,911 90,456 89,311 88,281 87,925 86,774 87,609 88,327 88,017DUALS 19,381 19,376 19,250 19,352 19,213 19,329 19,401 19,375 19,321 19,448 19,573 20,105 20,062SPD 10,438 10,277 10,282 10,246 10,321 10,326 10,319 10,219 10,236 10,215 10,150 10,125 9,867TLIC 29,858 29,788 30,238 29,858 29,682 29,038 29,495 29,831 30,047 30,390 30,868 30,357 31,723AE 57,340 57,796 57,307 56,731 56,843 56,680 56,580 56,434 56,461 56,250 56,802 56,781 54,991AE1 27% 28% 28% 27% 27% 28% 28% 28% 28% 28% 28% 28% 27%FAMILY1 44% 44% 44% 44% 44% 44% 44% 43% 43% 43% 43% 43% 43%DUALS1 9% 9% 9% 9% 9% 9% 9% 9% 9% 10% 10% 10% 10%SPD1 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%TLIC1 14% 14% 15% 14% 14% 14% 14% 15% 15% 15% 15% 15% 16%

14% 14% 15% 14% 14% 14% 14% 15% 15% 15% 15% 15% 16%

5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5% 5%

9% 9% 9% 9% 9% 9% 9% 9% 9% 10% 10% 10% 10%

44% 44% 44% 44% 44% 44% 44% 43% 43% 43% 43% 43% 43%

27% 28% 28% 27% 27% 28% 28% 28% 28% 28% 28% 28% 27%

0

25,000

50,000

75,000

100,000

125,000

150,000

175,000

200,000

225,000

Membership - Rolling 12 Month

SPD

SPD = Seniors and Persons with Disabilities TLIC = Targeted Low Income Children AE = Adult Expansion


For Reporting Period:39 40 41 42 43 44 45 46 47 48 49 50

10/1/2012 0 OCT 16 NOV 16 DEC 16 JAN 17 FEB 17 MAR 17 APR 17 MAY 17 JUN 17 JUL 17 AUG 17 SEP 1732 2 120+ 3.36 4.21 2.82 5.42 3.42 3.70 4.16 5.69 3.13 3.49 3.95 2.45

3 90 1.73 2.64 2.92 3.73 1.87 2.23 2.59 2.31 2.76 1.19 1.50 1.71 4 60 5.73 4.32 4.51 7.87 6.24 7.21 6.47 7.96 6.35 6.40 6.53 5.42 5 30 15.73 16.84 12.98 18.43 14.01 13.80 16.01 19.39 17.97 18.24 20.24 17.35

For the month ended February 28, 2014 6 Current 6.03 7.39 6.12 8.76 7.17 6.49 5.35 8.44 7.35 6.89 10.23 7.37 12 120+ 10% 12% 10% 12% 10% 11% 12% 13% 8% 10% 9% 7%13 90 5% 7% 10% 8% 6% 7% 7% 5% 7% 3% 4% 5%14 60 18% 12% 15% 18% 19% 22% 19% 18% 17% 18% 15% 16%15 30 48% 48% 44% 42% 43% 41% 46% 44% 48% 50% 48% 51%16 Current 19% 21% 21% 20% 22% 19% 15% 19% 20% 19% 24% 21%

SEPTEMBER 2017GOLD COAST HEALTH PLAN

Friday, August 01, 2014

OCT 16 NOV 16 DEC 16 JAN 17 FEB 17 MAR 17 APR 17 MAY 17 JUN 17 JUL 17 AUG 17 SEP 17Current 6.03 7.39 6.12 8.76 7.17 6.49 5.35 8.44 7.35 6.89 10.23 7.37 30 15.73 16.84 12.98 18.43 14.01 13.80 16.01 19.39 17.97 18.24 20.24 17.35 60 5.73 4.32 4.51 7.87 6.24 7.21 6.47 7.96 6.35 6.40 6.53 5.42 90 1.73 2.64 2.92 3.73 1.87 2.23 2.59 2.31 2.76 1.19 1.50 1.71120+ 3.36 4.21 2.82 5.42 3.42 3.70 4.16 5.69 3.13 3.49 3.95 2.45Current 19% 21% 21% 20% 22% 19% 15% 19% 20% 19% 24% 21%30 48% 48% 44% 42% 43% 41% 46% 44% 48% 50% 48% 51%60 18% 12% 15% 18% 19% 22% 19% 18% 17% 18% 15% 16%90 5% 7% 10% 8% 6% 7% 7% 5% 7% 3% 4% 5%120+ 10% 12% 10% 12% 10% 11% 12% 13% 8% 10% 9% 7%

10% 12% 10% 12% 10% 11% 12% 13% 8% 10% 9% 7%

5% 7% 10%8%

6% 7% 7% 5% 7% 3% 4% 5%

18% 12%15%

18%

19%22% 19%

18% 17%18% 15% 16%

48% 48% 44%

42%

43% 41% 46%

44%

48%50%

48%

51%

19%21%

21%

20%

22% 19% 15%

19%

20% 19%24%

21%

0

5

10

15

20

25

30

35

40

45

50

$ M

illio

ns

Paid Claims Composition (excluding Pharmacy and Capitation Payments)

5 *5 *

5 *

OCT 16 NOV 16 DEC 16 JAN 17 FEB 17 MAR 17 APR 17 MAY 17 JUN 17 JUL 17 AUG 17 SEP 17Prior Month Unpaid 35.98 39.12 40.94 43.98 36.66 40.73 41.27 40.74 34.37 35.01 35.32 33.39Current Month Unpaid 28.14 27.26 28.41 26.14 28.68 28.34 29.47 26.99 29.07 29.65 26.89 29.90Total Unpaid 64.12 66.38 70.12 62.14 65.34 69.07 70.74 67.73 63.44 64.65 62.21 63.29Current Month Unpaid 56% 59% 58% 71% 56% 59% 58% 60% 54% 54% 57% 53%Prior Month Unpaid 44% 41% 41% 42% 44% 41% 42% 40% 46% 46% 43% 47%

0

10

20

30

40

50

60

70

80

IBNP Composition (excluding Pharmacy and Capitation)

Note: Paid Claims Composition - reflects adjusted medical claims payment lag schedule.Months Indicated with 5* represent months for which there were 5 claim payments. For all other months, 4 claim payments were made.

$ M

illio

ns

Note: IBNP Composition - reflects updated medical cost reserve calculation plus total system claims payable.

5 *


AGENDA ITEM NO. 5

TO: Ventura County Medi-Cal Managed Care Commission FROM: Melissa Scrymgeour, Chief Administrative Officer DATE: December 4, 2017 SUBJECT: Contract Approval – Approval of Contract Extension and Additional Funding for

Emagined Security, Managed Information Security Services, Service Order Nos. 1 and 4

SUMMARY:

This contract is with Emagined Security. It includes (1) an extension from February 1, 2018 to January 31, 2020 to Service Order No. 1 for on-demand information security engineering and architecture services at a not-to-exceed amount of $152,000 for such period, and (2) a new Service Order No. 4 for additional managed security operations center (SOC) services for the period of January 1, 2018 to December 31, 2018, with a 12-month renewal option and a not-to-exceed amount of $178,750 for the two-year period. The total amount for the two Service Orders is $330,750 (See Table 1.) BACKGROUND/DISCUSSION: GCHP has an obligation to protect the privacy of our members’ health care information, maintain regulatory and contractual compliance with HIPAA and HITECH. Cyberattacks and data breaches in the healthcare industry are on the rise. The 2017 Ponemon Institute Annual Cost of Breach Study reported 106 major healthcare security breaches in 2016, impacting 13.5 million records at a total cost to the industry of $2.8B. The study also reports the average cost per breach per individual healthcare record is $380. GCHP must fortify our information security capabilities while maximizing the Plan’s information security investments to respond to the current and emerging information security threats to health care entities. The background on the specific services will be provided in an Attorney-Client Privileged memorandum that will be separately emailed to Commission members. FISCAL IMPACT: The current Service Order No. 1 for security services is funded for $173,000, with funding expected to be depleted by mid-January 2018. The additional estimated cost for continuing


these services through January 2020 is $152,000. This is a time and materials service order and is only billed if GCHP requires the services. The cost for the new two-year agreement for Service Order No. 4 is $178,750. Yr. 1 costs are estimated at $100,625, and Yr. 2 costs at $78,125. The total additional funding for both the Service Orders 1 and 4 is $330,750 over two years. (See Table 1.) Table 1: Info Sec Managed Services Costs Summary Year 1 Year 2 Total Yr1/Yr2 Service Order No. 4 $100,625 $78,125 $178,750 Service Order No. 1 $76,000 $76,000 $152,000 Total Additional Funding $176,625 $154,125 $330,750

RECOMMENDATION: It is the Plan’s recommendation to authorize the CEO to:

1. Execute an amendment to Emagined Security Service Order No. 1 to extend the term to 2/1/2018 to 1/31/2020 and fund an additional $152,000, and

2. Execute a new Emagined Security Service Order No. 4 for the period of 1/1/2018 to 12/31/2018, with a 12-month renewal option and a not to exceed amount of $178,750 for the two-year period.

If the Commission desires to review these contracts, they are available at Gold Coast Health Plan’s Finance Department.


AGENDA ITEM NO. 6

TO: Ventura County Medi-Cal Managed Care Commission FROM: Nancy Wharfield, Chief Medical Officer DATE: December 4, 2017 SUBJECT: Quality Improvement Committee Report The Department of Health Care Services requires Gold Coast Health Plan (GCHP) to implement an effective quality improvement system and to ensure that the governing body routinely receives written progress reports from the quality improvement committee. This report contains a summary of activities of the quality improvement committee and its subcommittees. APPROVAL ITEMS

• Beacon Health Options 2016 Quality Program Evaluation • Beacon Health Options 2017 Quality Program Description • Beacon Health Options 2017 Quality Improvement Work Plan • QI-002 External Accountability Set Performance Measures • QI-003 Primary care Provider Facility Site Review

OTHER QUALITY IMPROVEMENT ACTIVITIES HEDIS Data collection for MY2017 is currently in progress. Performance feedback reports are being distributed on a bi-monthly basis and outreach to clinic managers completed by the QI RN. The following measures are being monitored closely:

• Annual Monitoring for Patients on Persistent Medications o Ace Inhibitors or ARBS

Rate improved from 32.67 in Q1 to 60.70 in Q2 o Diuretics

Rate improved from 45.24 in Q1 to 63.37 in Q2 • Comprehensive Diabetes Care

o HbA1c Poor Control >9% Rate improved from 91.08 in Q1 to 85.65 in Q2 (a lower rate indicates

better performance) o HbA1c Adequate Control <8%

Rate improved from 6.76 in Q1 to 11.75 in Q2 o Retinal Eye Exam

Rate improved from 16.46 in Q1 to 26.01 in Q2 • Childhood Immunization Status

o Rate improved from 39.80 in Q1 to 49.40 in Q2


The National Committee of Quality Assurance (NCQA) is moving towards leveraging new data and a new process for reporting quality. NCQA is moving towards using Electronic Clinical Data Systems for reporting of HEDIS measures. Data sources used in ECDS includes the following:

• Electronic health records • Health information exchanges • Case management registry • Administrative claims

DHCS now requires GCHP to report the HEDIS ECDS measure; Depression Screening and Follow-Up for Adolescents and Adults IHA Monitoring (IHA) An IHA must be completed within 120 days of enrollment in GCHP. There was a slight improvement from Q1 to Q2.

Primary reasons for not achieving 100 % on medical record audits: Incomplete, unsigned, or no Staying Healthy Assessment in the medical record and/or age appropriate preventive health screenings were missing documentation in the medical record. Interventions during Q2 2017:

• Declines in medical record review compliance continue to be reviewed with medical providers and clinic managers at the end of each monthly review.

• Copies of each medical record review performed includes explanations in a comment column explaining to the provider what was missing in the medical record.

• Each summary score sheet includes instruction on the requirements for a completed SHA form.

• Continue to identify providers or clinics with problems. • Continue Network Provider Operations Department and Quality Improvement

Department monthly meetings.

Q-1 Q-22017 2% 3%

0%1%1%2%2%3%3%4%

Com

plia

nce

2017 Overall Percent of all IHA Criteria Met


• Continue to assist provider sites with concerns, problems, and provider efforts to improve IHA performance.

Facility Site Review Two (2) initial FSRs and 31 periodic FSRs were conducted in Q2 2017. All providers received passing scores. No Interim FSRs were due in Q2 2017. Smoking Cessation

Rates for counseling improved from 30% in Q1 to 75% in Q2. Offering of cessation medications also saw improvement from Q1 to Q2. Compliance Delegation Oversight

• No report presented; all metrics met Pharmacy

• 16 drugs reviewed o 7 were approved to be added to the formulary because they represent

significant clinical advantages Credentials/Peer Review

• Monitoring of Medical Board of California actions o Reviewed the status of 8 contracted providers with either Medical Board of

California actions or legal actions by the court. o 1 provider’s case with the Nevada State Board of Medical Examiners accepted

and approved a Settlement Agreement which ordered that the provider receive

Smoking Cessation Counseling Smoking Cessation MedicationOffered

Q-1 30% 17%Q-2 75% 25%

0%10%20%30%40%50%60%70%80%90%

100%

Com

plia

nce

2017 Overall Compliance


a public reprimand, complete 3 hours of CME, in addition to their statutory CME requirements for licensure, and reimburse the Board’s fees and costs incurred in the investigation and prosecution of the case against them.

o 1 provider with a legal case is scheduled for a court date on October 18, 2017

• Credentialing o 15 new providers were approved o 34 providers were recredentialed; one was pended o 45 facilities were credentialed o 1 facility was ineligible for credentialing due to inconsistencies on their

application

• Peer Review o 5 new PQI cases

4 are complete and closed 1 remaining open requiring a response from the provider, open in

medical record pursuit or review phase Cultural and Linguistics

• 56 outreach events • 4000 individuals reached • 14 in person interpreting services • 46 translation services • 108 sign language requests

Grievance and Appeals

• 608 Administrative grievances – top reason – Provider Disputes • 40 Clinical – top reasons were quality of care and accessibility • 17 Clinical Appeals: 9 upheld, 4 overturned, 4 withdrawn

Member Services

• Interactive Voice Response (IVR) 82% indicated that the IVR was “helpful” or “very helpful”

• Call Center Metrics – average speed to answer and abandonment rate goals were met

Network Operations • Provider visits metric not met due to critical regulatory project (274) and departure of

one provider representative Health Services Utilization Management Committee

• Turn around times met or exceeded goals • Denial rate remains consistent from quarter to quarter • Readmission rate has drifted up slightly and will continue to be closely monitored


• Reapproved Home Health Guidelines and Intravenous Sedation & General Anesthesia for Dental Service Guideline

• Revised and approved Diabetes Clinical Practice Guidelines Medical Advisory Committee (MAC) The following guidelines were approved at MAC:

• Custodial Care Guideline • Acute Rehabilitation Therapy Guideline • Transgender Services Guidelines • Chiropractic Services Guidelines

The Quality Improvement Dashboard can be found in the following pages.


Legend:Performance ≥ P90 PercentilePerformance < P90 PercentilePerformance ≤ P75 PercentilePerformance ≤ P50 PercentilePerformance ≤ P25 Percentile 8 2 0 1 7 8

Measure Description ResponsibleDepartment

BenchmarkSource

20143

Rate20154

Rate20166

Rate2017Q1

2017Q2

P25(MPL)

P50 P75 P90(HPL)

Annual Trend Interventions

ACE Inhibitors or ARBs 82.14 86.94 85.09 32.67 60.70 85.93 87.45 89.92 92.79

Digoxin 56.25 50.00 62.71

Diuretics 83.27 87.37 85.14 45.24 63.37 85.52 87.53 90.04 92.47

Total 82.30 86.74 84.95 41.16 61.16 85.21 87.25 89.59 91.84

(MPM) Annual Monitoring for Patients on Persistent Medications1) Bi-monthly clinic reports: HEDIS rates and performance feedback reports.performance feedback reports sent to clinics on 08/25/17.2) Lab reminder letters mailed to members in the MPM measure on 8/23/17.

The percentage of members 18 years of age and older who

received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement

year and at least one therapeutic monitoring event for

the therapeutic agent in the measurement year.

QualityImprovement HEDIS

Gold Coast Health Plan HEDIS Measures -- Quality of Care Indicators




BenchmarkSource

20143

Rate20154

Rate20166

Rate2017Q1

2017Q2

P25(MPL)

P50 P75 P90(HPL)


CDC: A1c Testing 90.51 88.56 86.86 25.20 54.28 84.25 85.96 89.43 92.82

1) Bi-monthly clinic reports: HEDIS rates and performance feedback reports.performance feedback reports sent to clinics on 08/25/17.

CDC: Poor A1c control(> 9.0%); lower rate is better 5

32.85 37.71 54.50 91.08 85.65 48.57 43.92 36.95 29.07


CDC: Good A1c control(< 8.0%); higher rate is better

57.91 54.50 36.98 6.76 11.75 41.94 46.72 52.55 59.12


CDC: Diabetic Eye Exam

60.10 81.51 50.61 16.46 26.01 47.57 53.49 61.69 68.33


CDC: LDL Testing 0.00 0.00

CDC: LDL Control(<100 mg/dL)

0.00 0.00

CDC: Nephropathy Monitoring

83.70 91.24 89.05 53.94 72.28 88.56 90.51 91.97 93.27


CDC: Blood Pressure (<140/90 mm Hg)

63.75 65.69 48.66 52.70 59.61 68.61 75.91


(CDC) Comprehensive Diabetes Care

The percentage of members that received a subset of services essential to diabetes management

QualityImprovement HEDIS





BenchmarkSource

20143

Rate20154

Rate20166

Rate2017Q1

2017Q2

P25(MPL)

P50 P75 P90(HPL)


CIS: Combo 3

The percentage of children 2 years of age that had DTaP, IPV, MMR, HiB, HepB, VZV, Pneumococcal Conjugate

QualityImprovement

HEDIS 69.97 75.43 64.96 39.80 49.40 65.25 71.06 75.60 79.32


2) Provider chid immunization memo on 07/11/17.

(CIS) Childhood Immunization Status



Met or exceeded BenchmarkDid not meet Benchmark

Measure Description BenchmarkSource

Benchmark 2014 2015 2016 2017Q1

2017Q2

Quarterly Trend Interventions

Facility Site Audit (Medi-Cal) - Scoring

The overall percentage of applicable DHCS site audit criteria met.

DHCS/ Title 22

80% 99% 92% 99% 96% 100%

Facility Site Audit (Medi-Cal) - Compliance

The percentage of providers that passed facility audits without or following completion of a corrective action plan.

DHCS/ Title 22

NA 100% 100% 100% 100% 100%

Medical Record Quality Audit (Medi-Cal) - Scoring

The overall percentage of applicable DHCS medical record audit criteria met.

DHCS/ Title 22

80% 96% 88% 94% 96% 97%

Medical Record Quality Audit (Medi-Cal) - Compliance

The percentage of providers that passed medical record audits without or following completion of a corrective action plan.

DHCS/ Title 22

NA 100% 88% 100% 100% 100%

Coordination of Care The overall percentage of applicable DHCS Coordination of Care criteria met as determined by medical record audits.

NA Tracking 100% 93% 99% 83% 100% On site instruction at time of medical record audit.

IHA Monitoring 1 The overall percentage of all IHA criteria met DHCS 100% NR NR 21% 2% 3%

Written instruction with each monthly audit.1 on 1 training to new provider sites.Group presentations to staff & provider groups when needed and/or requested.

Quality ImprovementLegend:


Measure Description Benchmark Source Benchmark 2015 2016 2017Q1

2017Q2


Delegation of UMNumber required & percentage of current delegates assessed

10-87128 Exhibit A, Attachment 5; NCQA Standard UM 15

DHCS Contract 100%1 100%4 100% 100%

Delegation of CRNumber required & percentage of current delegates assessed

Exhibit A, Attachment 4; NCQA Standard CR 9

DHCS Contract 10-87128 100%2 100%5 100% 100%

Delegation of QINumber required & percentage of current delegates assessed

10-87128 Exhibit A, Attachment 4; NCQA Standard QI 12

DHCS Contract 100%3 100%6 100% 100%

Delegation of RR Number required & percentage of current delegates assessed

10-87128 Exhibit A, Attachment 4; NCQA Standard RR 7

DHCS Contract 100%3 100%6 100% 100%

Delegation of Claims Number required & percentage of current delegates assessed

10-87128 Exhibit A, Attachment 8

DHCS Contract 100% 100%7 100% 100%


Delegation Oversight : Assessment of Delegated Quality ActivitiesLegend:


Measure DescriptionResponsible Department

Compliance Source Benchmark 2015 2016

2017Q1

2017Q2


PA AccuracyAll prior authorization requests were decided in accordance with GCHP clinical criteria.

Pharmacy DHCS Contract

99% 98% 98.76% 99% 100%

Weekly meetings with the PBM to clarify criteria and expectations for the decisions. Any approvals that the plan believes should have been denied, will remain and not be overturned. Any denials that the plan believes should have been approved are overturned and the member and physician are made aware of the approval.

PA TimlinessAll prior authorization requests were completed within 1 business day.


99% 98% 100% 100% 100%

Appropriate Decision Language on PA

All denied prior authorization requests contained appropriate and specific rationale for the denial

PharmacyDHCS

Contract 99% 98% 99.54% 99% 99%

GCHP is reviewing the denial language that is sent out and making revisions to the pre-set language as needed; this is an annual exercise and will continue going forward. Existing interventions include a second review of the language for all spelling, punctuation and grammar checks.

Annual Review of all UM Criteria

The P&T committee must review all utilization management criteria at least annually.

Pharmacy GCHP Met Met Met Met

Review of New FDA Approved Drugs

The P&T committee must review all new FDA approved drugs and/or all drugs added to the Medi-Cal FFS Contract Drug List.


Met Met Met Met


PharmacyLegend:


Measure Description Benchmark Source

Benchmark 2015 2016 2017Q1

2017Q2


Monitoring of Medicare/Medicaid sanctions

An OIG query is performed on every provider at the time of intitial and re-credentialing

DHCS/ Title 22

Standard met for 100% of files presented to CPRC

100% 100% 100% 100%

Monitoring of sanctions and limitations on licensure

An Medical Board of California (MBOC) query is performed on every provider at the time of initial and re-credentialing. Other state licensing boards are also queried as needed

DHCS/ Title 22


100% 100% 100% 100%

Monitoring of ComplaintsMember complaint data is considered during re-credentialing.

DHCS/ Title 22


NA NA NA NA

Quality of Care concerns are reviewed at a minimum of every 6 months and are forwarded to Credentials/Peer Review Committee (CPRC) as indicated.

DHCS/ Title 22 Biannually 100% 100% 100% 100%

HIPDB queries are performed within 180 days prior to the date of initial and re-credentialing

DHCS/ Title 22


100% 100% 100% 100%

Timeliness of provider notification of credentialing decisions

Providers will be notified of the credentialing decision in writing within 60 days

DHCS/ Title 22


100% 100% 100% 100%

Timeliness of verifications

All credentialing verifications are performed within 180 days prior to the credentialing date, as required

DHCS/ Title 22


98% 98% 99% 98%

Q2: Several factors contribued to drop in percentage. Main factors High volume of practitioners being credentialed this year, practitioners not submintting needed attestation within a timely manner.

# of provider terminations for quality issues

Credentials/Peer Review Committee (CPRC) denial of a credentialing application for quality issues will cause termination of the provider from the network

DHCS/ Title 22


None None None None

Monitoring of adverse events

CredentialsLegend:

Access Indicators




Benchmark 2015 2016 2017Q1

2017Q2


Timeliness of processing of initial applications

Initial applications will be processed within 90 days

DHCS/ Title 22

Standard met for 90% of applications received

93% 97% 99% 96%

Timeliness of processing of re-credentialing applications

Recredentialing applications will be processed within 90 days

DHCS/ Title 22

Standard met for 90% of applications received

95% 96% 98% 90%

Timeliness of Physician Recredentialing

Percent of physicians recredentialed within 36 months of the last approval date

NCQA: CR Standards

Standard met for 90% of providers

93% 94% 99% 98%

Continuous Monitoring of Allied Providers

Percent of allied providers' expirable elements that are current

NAStandard met for 90% of elements

100% 100% 100% 100%

Timeliness of Organization Reassessment

Percent of organizations reassessed within 36 months of the last assessment

NCQA: CR Standards

Standard met for 90% of providers

98% 95% 100% 90%

CredentialsLegend:

Access Indicators




Benchmark 2016 2017Q1

2017Q2


Sign Language Services Percent of sign language services fulfilled DHCS/Title 22 100% 89% 100% 100%

Did not meet Benchmark

Cultural & Linguistics (C&L)Legend:Met or exceeded Benchmark


Measure Description Compliance Source

Benchmark 2015 2016 2017Q1

2017Q2


Resolution Turnaround Times (TAT) Grievances

100% TAT within 30 calendar days GCHP 100% 76% 99% 77% 99%

Post Service TAR Provider Appeals Processing Time - Resolution

The percentage of provider appeals processed within 30 business days from receipt.

GCHP 100% 100% 99% 97% 100%

Provider Grievances: Complaint, Appeal, or Inquiry

Timely resolution of provider grievances GCHP 100% 66% 99% 99% 99%

Monitoring of ComplaintsMember complaints are monitored at a minimum of every six months to assess for trends/outliers

GCHP Monitoring 100% 100% 100% 100%

Grievance & AppealsLegend:Met or exceeded BenchmarkDid not meet Benchmark


Measure Description ComplianceSource

Benchmark 2015 2016 2017Q1

2017Q2


Call Center - Aggregate Average Speed of Answer (ASA)

Average Speed to Answer(in seconds)

<= 30 seconds 57.5 29.5 23.0 22.3

Call Center -Aggregate Abandonment Rate

Percentage of aggregate Abandoned calls to Call Center <= 5% 16.7% 1.30% 1.30% 1.02%

Call Center - Aggregate Call Center Call Volume

Monitored to ensure adequate staffing and identification of systemic issues.

117,039 121,068 34,882 33,705

Call Center - IVR Satisfaction Survey

Combined percentage of callers who answered "Very Helpful" and "Helpful" to their IVR satisfaction

80.29% 83.69% 82.30%

Did not meet Benchmark

Member ServicesLegend:Met or exceeded Benchmark


Legend:



2016Q3

2016Q4

2016 2017Q1

2017Q2


# & geographic distribution of PCPs

Network of PCPs located within 30 minutes or 10 miles of a member's residence to ensure each member has a PCP who is available and physically present at the service site for sufficient time to ensure access for assigned members upon member's request or when medically required and to personally manage the member on an on-going basis.

DHCS, Exhibit A, Attachment 6

Standard met for minimum 95% of members

Met 99.9% 99.9% 99.9% 99.8% 99.9%

# & geographic distribution of SCPs

Adequate numbers and types of specialists within the network through staffing, contracting, or referral to accommodate members' need for specialty care.



Met 99.6% 99.6% 99.6% 99.7% 99.9%

Ratio of members to physicians

1:1200 DHCS, Exhibit A, Attachment 6

Standard met for 100% of members

Met 1:193 1:217 1:205 1:217 1:39

Reduction in ratio due to the inclusion of new specialist physicians from CHLA, City of Hope (COH) & UCLA.

Ratio of members to PCPs

1:2000 DHCS, Exhibit A, Attachment 6


Met 1:867 1:848 1:856 1:848 1:504

Acceptable driving times and/or distances to primary care sites

30 minutes or 10 miles of member's residence



Met Met Met Met 99.8% 99.9%


Network Operation QI Dashboard - Access and Availability

Access to Network / Availability of Practitioners


Legend:



2016Q3

2016Q4

2016 2017Q1

2017Q2


After Hours Access

Providers have answering machine or service for after-hours member calls



72.2%

72.2% met the criteria however still fell short of benchmark. Providers who did not meet standards, a plan to educate/correct those who did not meet timely access After-Hours standard is in development. Awaiting meeting set-up with Vendor to discuss next steps / timeframe of surveys.

After-hours machine messages or service staff is in threshold languages



Provider After-Hour (SPH Analytics) Script missing language threshhold, therefore not surveyed. Will include in next survey, also remind those who did not meet timely access After-Hours standard recordings must be in English and Spanish. Awaiting meeting set-up with Vendor to discuss next steps / timeframe of surveys.

After-hours answering machine message or service includes instructions to call 911 or go to ER in the event of an emergency



NA 71.2%

Awaiting meeting set-up with Vendor to discuss next steps / timeframe of surveys.




After Hours Access


Legend:



2016Q3

2016Q4

2016 2017Q1

2017Q2


Urgent Care appointments for services that do not require prior authorization: within 48 hours of the request for appointment

DHCS, Exhibit A, Attachment 9 NA 100%

Based on DMHC standard of 48 hrs.

Non-urgent appointments for primary care: within 10 business days of the request for appointment

DHCS, Exhibit A, Attachment 9 NA 90.2%


Non-urgent appointments with specialist physicians: within 15 business days of the request for appointment

DHCS, Exhibit A, Attachment 9 NA 48.4%


Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within 15 business days of the request for appointment


NA 23.5%


Appointment Availability

Availability of appointments within GCHP's standards by type of encounter

DHCS, § 7.5.4Standards met for minimum of 95% of providers

NA

In discussion with vendor to repeat survey for Q4, awaiting meeting set-up with Vendor to discuss next steps / timeframe of surveys.

Provider Surveys Measure provider satisfaction GCHP

Satisfaction expressed in each of 6 areas for 80% of providers

Not Met

In discussion with vendor to repeat survey for Q4, awaiting meeting set-up with Vendor to discuss next steps / timeframe of surveys.

Time Elapsed Standards

Standards met for minimum of 90% of providers





Legend:



2016Q3

2016Q4

2016 2017Q1

2017Q2


Provider Training

Number of new PCPs / Providers receiving orientation within 10 days of contracting (Note: Provider is offered an orientation within 10 days, but may be completed within 30 days, or if provider declines training, a declination req'd )

DHCS Exhibit A, Attachment 7

100% within 10 days of contracting

Met 100% 100% 100% 100% 100% 100%

Provider VisitsNumber of Provider Services Representative provider visits GCHP

Department goal = 100/quarter (400/year) *Based on 2 PR Reps.

Met 167 121 104 392 95 42

Slight decrease in department goal per quarter due to critical regulatory project (274) as well as a departure of one of the provider reps. Current benchmark based on 1 PR Rep. Dept. goal = 60/quarter (240/year).





AGENDA ITEM NO. 7 TO: Ventura County Medi-Cal Managed Care Commission FROM: Dale Villani, Chief Executive Officer DATE: December 4, 2017 SUBJECT: State of California Contract Amendment A25 SUMMARY: The State of California Department of Health Care Services (DHCS) establishes monthly capitation payments by major Medi-Cal population groups and updates them periodically to reflect policy changes and other adjustments. Amendment A25 reflects expected changes to Gold Coast Health Plan (GCHP or Plan) capitation rates for FY2015-16. BACKGROUND/DISCUSSION: GCHP received a contract amendment from DHCS on October 30, 2017, which updates the Plan’s FY2015-16 capitation rates for certain Medi-Cal aid codes as follows:

• The amendment memorializes the FY2015-16 rates for the Classic and Adult Expansion (AE) populations. The AE rate also includes additional rate range funding for the county facility pursuant to Assembly Bill (AB) 85.

• The amendment adds new rates for Hepatitis C drugs and BHT Services during FY2015-16. Rates are the basis for supplemental payments for each member that utilizes these services.

• The amendment also adds six aid codes to the existing Adult and Child aid category. FISCAL IMPACT: Amendment A25 memorializes rates included in a rate package received by GCHP on various dates throughout the year. The capitation rates for the FY2015-16 apply to the Classic and AE populations. As the Plan had recorded revenue based on the rates in the rate package, there is no impact to the Plan’s net assets. The AB85 funding included in the AE rates has been treated as a pass-through item and has not impacted the Plan’s net assets.


RECOMMENDATION: Staff is recommending the Commission approve and authorize the CEO to execute DHCS contract Amendment A25. CONCURRENCE N/A Attachments None


AGENDA ITEM NO. 8 TO: Ventura County Medi-Cal Managed Care Commission FROM: Dale Villani, Chief Executive Officer DATE: December 4, 2017 SUBJECT: State of California Contract Amendment A26 SUMMARY: The State of California Department of Health Care Services (DHCS) establishes monthly capitation payments by major Medi-Cal population groups and updates them periodically to reflect policy changes and other adjustments. Amendment A26 reflects changes to Gold Coast Health Plan (GCHP or Plan) capitation rates for FY2016-17. BACKGROUND/DISCUSSION: GCHP received a contract amendment from DHCS on October 30, 2017, which updates the Plan’s FY2016-17 capitation rates for certain Medi-Cal aid codes as follows:

• The amendment revises the FY2016-17 rates for the Classic and Adult Expansion (AE) populations to include funding for MCO tax.

• The amendment adds new rates for Hepatitis C drugs and BHT Services during FY2016-17. Rates are the basis for supplemental payments for each member that utilizes these services.

FISCAL IMPACT: Amendment A26 memorializes rates included in a rate package received by GCHP on December 6, 2016. The capitation rates for the FY2016-17 apply to the Classic and AE populations. As the Plan had recorded revenue based on the rates in the rate package, there is no impact to the Plan’s net assets. RECOMMENDATION: Staff is recommending the Commission approve and authorize the CEO to execute DHCS contract amendment A26. CONCURRENCE: N/A ATTACHMENTS: None


AGENDA ITEM NO. 9

TO: Ventura County Medi-Cal Managed Care Commission FROM: Dale Villani, Chief Executive Officer DATE: December 4, 2017 SUBJECT: State of California Contract Amendment A27 SUMMARY: The State of California Department of Health Care Services (DHCS) establishes monthly capitation payments by major Medi-Cal population groups and updates them periodically to reflect policy changes and other adjustments. Amendment A27 reflects changes to Gold Coast Health Plan (GCHP or Plan) capitation rates for FY2014-15. BACKGROUND/DISCUSSION: GCHP received a contract amendment from DHCS on October 30, 2017, which updates the Plan’s FY2014-15 capitation rates for certain Medi-Cal aid codes as follows:

• The amendment adjusts the FY2014-15 rates for the second half of the fiscal year (January 1, 2015 to June 30, 2015) to include the Hospital Quality Assurance Fee (HQAF) pursuant to Senate Bill (SB) 239 for the Adult Expansion population.

FISCAL IMPACT: Amendment A27 increased capitation rates for the FY2014-15 SB239 funds, and enabled GCHP to receive approximately $11.6 million for distribution to various hospitals that serve Medi-Cal and uninsured patients. The allocations of distributions was determined by the California Hospital Association. As a pass-through item, there was no impact to the Plan’s net assets. RECOMMENDATION: Staff is recommending the Commission approve and authorize the CEO to execute DHCS contract amendment A27. CONCURRENCE: N/A ATTACHMENTS: None


AGENDA ITEM NO. 10

TO: Gold Coast Health Plan Commission FROM: Joseph T. Ortiz, Best Best & Krieger LLP- Diversity Counsel DATE: December 4, 2017 SUBJECT: Chief Diversity Officer SUMMARY: The Diversity Subcommittee is pleased to announce that Theodore Bagley dba TBJ Consulting (“TBJ Consulting”) has agreed to work on an capacity as Gold Coast Health Plan’s Chief Diversity Officer (“CDO”). TBJ Consulting has previously provided interim CDO services to Gold Coast Health Plan (“Plan”). Following negotiations, TBJ Consulting has agreed to the following terms, subject to approval by the Commission: (1) an hourly rate of $250.00 per hour of work; with (2) an anticipation of twenty1 hours per month, totaling approximately $5,000.00 per month. Thus, the anticipated annual impact shall be approximately $60,000.00. The proposed Consulting Services Agreement is attached hereto as Exhibit 1. Pursuant to Statement of Work, TBJ Consulting will perform all duties as outlined in the CDO job description, including but not limited to the investigation and reporting on all diversity-related issues. Per the requirements of the CDO position, TBJ Consulting will report directly to the Commission and will issue quarterly reports to the Commission and the Ventura County Board of Supervisors. Should this contract be accepted, TBJ Consulting will start work immediately and will continue until the Plan hires a permanent CDO. BACKGROUND/DISCUSSION: On October 6, 2015, the Ventura County Board of Supervisors adopted Ordinance 4481, which required that the Plan to establish a Cultural Diversity Program. Section 1382 of Ordinance 4481 also called for the creation of the CDO position to oversee the program. After creating the job description, the Plan used consultants, including TBJ Consulting, to provide CDO services while recruitment efforts for a permanent CDO were underway. After an extensive recruitment

1 While the contract anticipates twenty (20) hours per month on a regular basis, Mr. Bagley will orally request that the Commission authorize up to forty (40) hours per month for the first two months of the contract. The additional time is requested in order to re-establish community ties and ramp back up the GCHP diversity program. Should the request be approved, there will be $10,000 of added annual impact.


effort, the Plan hired Douglas Freeman as CDO on April 10, 2017. Unfortunately, Mr. Freeman left the position as of September 8, 2017, and the Plan is in need of CDO services. FISCAL IMPACT: Approximately $60,000 in annual consulting fees. RECOMMENDATION: Staff recommends that the Commission approve and ratify the proposed Consulting Services Agreement and Statement of Work. CONCURRENCE: N/A ATTACHMENT: Exhibits 1


















AGENDA ITEM NO. 11 TO: Ventura County Medi-Cal Managed Care Commission FROM: Ruth Watson, Chief Operating Officer DATE: December 4, 2017 SUBJECT: Office Sublease Agreement, 711 Daily Drive Suites 105 and 107. SUMMARY: Gold Coast Health Plan (GCHP) currently leases space at 711 Daily Drive and 770 Paseo Camarillo in Camarillo. As Medi-Cal membership across the state and in Ventura County has decreased, the accompanying staffing projections and space needs have also decreased. Consequently, GCHP leadership staff has identified two suites on the first floor at 711 Daily Drive that present potential sublease opportunities. BACKGROUND/DISCUSSION: The Plan has sought and been granted permission by the 711 building ownership to sublet two suites currently leased to GCHP, relocating impacted employees to available space on the 2nd floor. Suite 105 consists of 2,578 rentable square feet (RSF) while suite 107 comprises 1,303 RSF. Staff has begun working with NAI Capitol to develop two proforma scenarios showing projecting gross revenue if the space is sublet. It is the Plan’s recommendation to pursue the sublease of suites 105 and 107 at 711 Daily Drive in Camarillo, utilizing William Kiefer at NAI Capitol to conduct a marketing campaign on behalf of GCHP and allow the CEO to enter into a 3-year agreement with a potential sub-lessor to occupy the above-mentioned space. FINANCIAL IMPACT: Projected Economics* - attached are two spreadsheets showing gross revenue for two proforma scenarios with the following terms:

• 3-year term • modest rent ($1.85 per RSF is 12% less than market due to the nature of a sublease) • one-half month rent discount for each lease year • nominal Tenant Improvement costs ($1 per RSF) and • 7% broker commission (half likely to cooperating broker)


• Suite #105 shows $155,600 Cumulative Cash Flow • Suite #107 shows $78,600 Cumulative Cash Flow

*These numbers represent savings to our current rent obligation

RECOMMENDATION: Subject to review by legal counsel, authorize and direct the Chief Executive Officer to execute an agreement with NAI Capital to represent GCHP as the Plan’s exclusive agent for sublease of Suites 105 and 107 at 711 East Daily Drive. CONCURRENCE: None ATTACHMENTS: None


SPACE DETAILS

Use: OfficeSuite: #105Rentable SF: 2,578Useable SF (Core %): 2,404 (7.24%)

LEASE TERMS

Lease Start: 1/1/2018 Free Rent: 1.5 Months ($7,154)Lease End: 12/31/2020 Service Type: Full Service (No Pass-Thru)Term: 3 Years Operating Exp: N/AStarting Rent: $1.85 / RSF Commission: 7.00%Rent Increases: 3% Annual Steps Improvements: $1.00 / RSF (Landlord Allowance)

Year 1 Year 2 Year 3 TotalBase Rent 57,232 57,232 57,232 171,695Escalations - 1,717 3,485 5,202Free Rent (7,154) - - (7,154)

Total Base Rent 50,078 58,949 60,717 169,743

Total Rent 50,078 58,949 60,717 169,743

Net Operating Income 50,078 58,949 60,717 169,743

Lease Commissions 11,518 - - 11,518Improvement Allowance 2,578 - - 2,578

Total Other Costs 14,096 - - 14,096

Cash Flow 35,982 58,949 60,717 155,647Cumulative Cash Flow 35,982 94,930 155,647 155,647

Proposal Cash Flow Owner Perspective

711 E Daily Dr - Camarillo Business Center IICamarillo, CA 93010

DEAL:MODEL: Projected Sublease Terms

Proforma Sublease Economics | Suite #105

©2015 CoStar Realty Information, Inc. - 83104

The analysis contained herein is based on assumptions and estimates which have not been (orcannot be) independently verified and are subject to change. No representation or warranty ismade as to the accuracy or completeness of the analysis and all information herein is providedas is. The analysis herein should not be construed as investment, tax or legal advice.

11/8/2017


LEASE TERMS


SPACE DETAILS


FREE RENT

Lease Month # of Months % Free

1 1.5 100%

BASE RENT (Full Service (No Pass-Thru))

Date Amount Increase

Month Date $ / RSF $ / Month $ / RSF $ / Month %

1 1/1/2018 1.85 4,769

13 1/1/2019 1.91 4,912 0.06 143 3.00

25 1/1/2020 1.96 5,060 0.06 147 3.00

TENANT IMPROVEMENTS

$ / RSF Amount

Improvement Costs 1.00 2,578

Less: Landlord Contribution 1.00 2,578

Net Cost to Tenant 0.00 0

RECOVERIES

Service Type: Full Service (No Pass-Thru)

SETTINGS

Discount Rate: 5%

IRR Investment Basis: None

IRR Exit Cap Rate: None

Base Rent Input: Monthly Basis

Fiscal Year End: December

Currency: US Dollars

Area Measure: Square Feet

INFLATION

2018 2019 2020 2021 2022 2023 2024 2025 2026 2027

Global Inflation 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00%

Consumer Price Index (CPI) 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00%

Proposal Input Detail Owner Perspective






11/8/2017






DEAL DETAILS

General Comments

Sample proforma economics for new 36 month sublease.



11/8/2017


SPACE DETAILS


LEASE TERMS


Year 1 Year 2 Year 3 TotalBase Rent 28,927 28,927 28,927 86,780Escalations - 868 1,762 2,629Free Rent (3,616) - - (3,616)

Total Base Rent 25,311 29,794 30,688 85,793

Total Rent 25,311 29,794 30,688 85,793

Net Operating Income 25,311 29,794 30,688 85,793

Lease Commissions 5,821 - - 5,821Improvement Allowance 1,303 - - 1,303

Total Other Costs 7,124 - - 7,124

Cash Flow 18,186 29,794 30,688 78,669Cumulative Cash Flow 18,186 47,981 78,669 78,669

Proposal Cash Flow Owner Perspective






11/8/2017


LEASE TERMS


SPACE DETAILS


FREE RENT

Lease Month # of Months % Free

1 1.5 100%

BASE RENT (Full Service (No Pass-Thru))

Date Amount Increase

Month Date $ / RSF $ / Month $ / RSF $ / Month %

1 1/1/2018 1.85 2,411

13 1/1/2019 1.91 2,483 0.06 72 3.00

25 1/1/2020 1.96 2,557 0.06 74 3.00

TENANT IMPROVEMENTS

$ / RSF Amount

Improvement Costs 1.00 1,303

Less: Landlord Contribution 1.00 1,303

Net Cost to Tenant 0.00 0

RECOVERIES

Service Type: Full Service (No Pass-Thru)

SETTINGS

Discount Rate: 5%

IRR Investment Basis: None

IRR Exit Cap Rate: None

Base Rent Input: Monthly Basis

Fiscal Year End: December

Currency: US Dollars

Area Measure: Square Feet

INFLATION

2018 2019 2020 2021 2022 2023 2024 2025 2026 2027

Global Inflation 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00%

Consumer Price Index (CPI) 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00% 3.00%







11/8/2017






DEAL DETAILS

General Comments

Sample proforma economics for new 36 month sublease.



11/8/2017


AGENDA ITEM NO. 12

TO: Ventura County Medi-Cal Managed Care Commission

FROM: Dale Villani, Chief Executive Officer DATE: December 4, 2017 SUBJECT: Begin Process to Secure Additional Medi-Cal Funds through an Intergovernmental

Transfer (IGT) SUMMARY: Authorize and direct the Chief Executive Officer to submit a proposal to the California Department of Health Care Services (DHCS) to begin the process to secure additional Medi-Cal Funds through an Intergovernmental Transfer (IGT). The proposal would include a voluntary letter of interest and additional documentation from the funding entity (i.e., Ventura County Medical Center (VCMC) or other appropriate County agency). BACKGROUND: Intergovernmental Transfers (IGTs) are a mechanism for Medi-Cal managed care plans, counties and certain types of public hospitals to work with the State of California to bring federal Medicaid matching dollars to the local level. To accomplish an IGT, a “funding entity” provides funds to the State Department of Health Care Services (DHCS). A funding entity can be counties, cities and State University teaching hospitals, or any other political subdivision of the State, as long as they meet the requirements as defined by 42 C.F.R. Section 433, Subpart B for the funding of IGTs. The federal government then matches those funds according to a set formula. The State uses these combined funds to increase the rates it pays to the local Medi-Cal managed care plan consistent with the Plan’s actuarially determined payment rates. The funding entity recoups the original outlay of funds and the federal match to those funds. DISCUSSION: The proposed IGT is expected to be structured similar to prior years’ IGTs with the added requirement that the ultimate payments must be tied to covered Medi-Cal services for enrolled beneficiaries. An initial transfer of funds from the funding entity to DHCS will be required. The DHCS would then use a portion of these funds to leverage a federal match at the Federal Medical Assistance Percentages (FMAP) rate in effect during Fiscal Year 2017-18. A portion of the funds (20%) would be paid to DHCS as an assessment fee. Subsequently, Gold Coast Health Plan (GCHP or Plan) would receive an increased capitation via a rate amendment to


the Primary Agreement between GCHP and DHCS. The Plan would return the funds received via the increased capitation rate to the funding entity, after withholding an administrative fee (expected to be 2%). GCHP received a letter from DHCS on November 15th that required the Plan and funding entities to provide the required materials no later than December 14, 2017. GCHP would need to provide the State with a proposal that would include:

• the Plan’s contact person, funding entity and participation levels (i.e., expected percentage of dollars to fund); and

• the funding entity’s voluntary letter of interest. The funding entity is also required to submit specified cost data to DHCS by the due date. FISCAL IMPACT: The impact to the Plan’s FY2017-18 revenue due to the IGT is estimated to be $695,000. RECOMMENDATION: Authorize and direct the Chief Executive Officer to provide DHCS with a proposal (including information from the funding entity) to the State of California. CONCURRENCE: N/A. ATTACHMENTS: None.


AGENDA ITEM NO. 13 TO: Ventura County Medi-Cal Managed Care Commission FROM: Dale Villani, Chief Executive Officer DATE: December 4, 2017 SUBJECT: Chief Executive Officer Update

Continued Diligence on TNE and Healthcare Expenses

As discussed, GCHP continues to monitor health care expenses against revenue as part of our TNE plan. The higher health care expenses are driven primarily by higher provider contract

rates. These higher rates allowed GCHP to bring down our reserves to the approved TNE policy levels. However, the Plan must now renegotiate or restructure these rates to maintain appropriate reserves.

GCHP is moving to alternative reimbursement models (APMs) to be consistent with CMS and DHCS direction. We are also assessing contracted out of area tertiary care services, which encompass approximately 21% of the hospital related healthcare expenses. The Plan is also assessing narrow networks for

ancillary care services, which could provide preferred pricing.

The executive/finance committee reviewed the current health care expense trends and discussed alternative options for bringing expenses in line with our budgeted MLR. The committee directed to meet monthly for the next six months to review Plan actions.

GCHP in the Community

Oxnard Chamber of Commerce

Last month, the Oxnard Chamber of Commerce, held its annual Oxnard Business Outlook event. Loren Kaye, President of the California Foundation for Commerce and Education was the keynote speaker. Mr. Kaye provided a brief overview of the voter survey recently conducted by the California Chamber of Commerce. The survey revealed that the most pressing issues for Californians were around public roads, jobs, and housing.

Figure 1 - GCHP Quarterly Summary

Figure 2 - Oxnard Chamber health care panel


The second half of the program was comprised of a panel of local health care experts providing their own insight around the future of healthcare. The panel was comprised by:

• Dale Villani, CEO of Gold Coast Health Plan • Darren Lee, President and CEO of St. John’s Regional Medical Center • Kelly Bruno, President and CEO of the National Health Foundation • Adam Cavallero, MD, Assistant Clinical Professor of Medicine at the David Geffen School

of Medicine at UCLA The panel discussed the importance of addressing the social determinants of health, access to care, and universal healthcare.

Federal Update

Children Health Insurance Program (CHIP) Update

Last month, the House passed H.R.3922, the Championing Healthy Kids Act of 2017. The bill would provide a 5-year funding extension for CHIP, but would eliminate the enhanced federal match provided under the Affordable Care Act (ACA). The bill also would eliminate the reductions in Medicaid Disproportionate Share Hospital funding scheduled for FY 2018 and 2019 as well as extend funding for community health centers, the National Health Service Corps and other public health programs. The House bill included a number of funding offsets, including a significant reduction in funds for the Affordable Care Act’s (ACA) Prevention and Public Health Trust Fund.

The Senate version of the bill, which has moved out of the Finance Committee, does not include any offsets, and Senate staff continue to discuss potential funding sources for the bill. Because the bill will need 60 votes to pass the Senate, it is unclear whether they will be able to come to an agreement on acceptable offsets; it is likely the final CHIP bill will reflect the Senate Finance Committee version of the bill.

Association of Community Affiliated Plans (ACAP) Board Meeting

In November, ACAP held its quarterly Board/Marketplace meeting. Board members had the opportunity to listen to various experts in health policy discuss current legislative issues and upcoming policy trends for next year. Issues discussed were the following:

• CHIP: The program will most likely will be included in the end-of-the-year omnibus package.

• Buy-In Proposals: Senator Brian Schatz (D-HI) and House Representative Michelle Lujuan (D-NM) introduced S.2001 and H.R. 4129, which would allow individuals to buy-into the Medicaid program. Senator Bernie Sanders (D-VT) introduced S. 1804, which would create a single-payer health care program.

• Medicaid Workforce Requirements: During the National Association of Medicaid Directors meeting, Seema Verma, Administrator for the Center for Medicare and


Medicaid Services (CMS), indicated that the federal government would support states’ proposals to impose work or community engagement requirements to their Medicaid program.

• State Flexibility: the National Conference of State Legislatures briefed ACAP plans on the flexibility that 1115 and 1332 waivers provide to states and the possible role these waivers will have in the future.

The Government Relations team will monitor the items discussed above and provide updates in the upcoming year, as new information is available.

State Update

Despite the California Legislature being out of session, committees have held various hearing around universal healthcare coverage and maintaining adequate provider networks. Below is a summary of both hearings.

Universal Coverage Hearings

The Assembly Select Committee on Healthcare Delivery Systems and Universal Coverage held the first two of a series of hearings designed to develop a plan for California to achieve universal coverage.

Committee members heard from various policy experts and academicians on issues ranging from the financing of existing health care markets, California’s uninsured population, and models for achieving universal coverage from other countries. The hearings were not intended to deliberate SB 562, the single-payer bill that was held in the Assembly this past legislative session.

The co-chairs of the select committee stated that follow-up hearings would focus on implementation challenges to universal coverage and comparing and contrasting different proposals.

Hearing dates are forthcoming.

Senate Budget Subcommittee on Health and Human Services

The Senate Budget Subcommittee on Health and Human Services held an oversight hearing last month entitled “Achieving and Maintaining Adequate Provider Networks in Medi-Cal Managed Care.”

The Chair of the Subcommittee Senator Richard Pan (D-Sacramento) stated in his opening remarks that the purpose of the hearing was to focus on how Medi-Cal managed care plan rates are established and what is done to oversee the adequacy of provider networks. Senator Pan added that with an estimated 80 percent of the Medi-Cal population in managed care, it is critical to monitor how it is working.


Mari Cantwell, Chief Deputy Director of Health Care Programs, Department of Health Care Services was the first witness. Director Cantwell provided an overview of the rate setting process and complimented the success of the standing workgroup that was established to develop rates for the expansion population. She then walked through the Medicaid Final Rules promulgated by the federal government and how she will be responsible for certifying network standards. She went over the network oversight tools and the process that DHCS has in place; including the monthly provider file, technical assistance, and corrective action plans.

The second panel was comprised of Medi-Cal managed care plans. It included representatives from local and commercial plans. The panel explained how health plans develop their networks and how they address network adequacy issues.

The third panel provided a forum for interest groups to discuss the issues they see around provider networks and beneficiary access. Among their issues was a perceived lack of oversight and monitoring for independent practice associations (IPAs). Additional comments were made regarding slow responses to consumer complaints, long appointment wait times, lack of specialty provider types, and translation services.

Senator Pan closed the hearing after public comments and announced that the next oversight hearing will be on mental health.


AGENDA ITEM NO. 14 TO: Ventura County Medi-Cal Managed Care Commission FROM: Brandy Armenta, Compliance Officer DATE: December 4, 2017 SUBJECT: Compliance Update DHCS Annual Medical Audit: Audits and Investigations (A&I) conducted the annual onsite medical audit during the weeks of June 5, 2017 through June 16, 2017. Gold Coast Health Plan (GCHP) is anticipating a draft report which A&I has confirmed for a release of the report in January 2018.Staff will keep the commission apprised as GCHP receives information. DHCS Contract Amendments: The draft DHCS contract amendment (version 2) was sent to Plans in April of 2017. The amendment is still under review by CMS and the Plan is pending the final amendment for signature. The amendment incorporates approximately 156 Mega Reg provisions. Approximately 63 items remained TBD for the State to define and 28 items are TBD and not in the contract amendment. Additional provisions and requirements will be forthcoming via additional contract amendments, all plan letters, policy letters etc. GCHP was required to submit Final Rule (Mega Reg) deliverables to DHCS based on the draft contract amendment in May 2017. Delegation Oversight: GCHP is required to monitor functions delegated to all entities who perform a function on behalf of the Plan. Compliance is responsible for ensuring functions in which are delegated are performed in compliance with all applicable regulations and requirements. GCHP monitors delegates through ongoing contractual reporting/monitoring as well as conducting onsite audits. During an onsite audit if a subcontractor does not meet contractual requirements or substantial deficiencies are identified, a six-month onsite follow up audit is conducted. The audit results and report outcomes is a standard report to the GCHP Compliance Committee and Quality Improvement Committee. The information provided below outlines delegation activity conducted by GCHP for calendar year 2017.


DO General Overview

Corrective Action Plans (CAPs) issued CY2017 3 CAPs closed 4 CAPs being monitor 2 Audits Conducted CY 2017 12

Corrective Action Plans (CAPs) As referenced in the table above, Compliance issued three CAPs during CY 2017. GCHP issued a CAP to Kaiser for failure to meet contractual service level agreement (SLA) of ninety percent (90%) of claims adjudicated within thirty (30) days. As a condition of the CAP, Kaiser was required to provide routine project improvement updates on a monthly basis. Kaiser was able to meet the required SLA and adjudicate over 90% of claims within 30 days for 2 consecutive quarters. GCHP closed the CAP in November 2017. Compliance issued a CAP to Beacon Health Options (Beacon) after identifying a deficiency in acknowledging paper claims. Beacon was able to remedy the finding by allocating additional resources to claims processing. Beacon demonstrated sustained significant improvements and compliance. Compliance was able to lift the financial sanction imposed on Beacon based on a 2016 audit as well as close out the CAP from 2016 and 2017. Compliance issued a CAP to VSP in 2015 for failure to comply with the Medi-Cal ‘Six-month Billing Limit’. VSP’s opposition to the finding subsequently resulted in GCHP contacting the California Department of Health Care Services (DHCS) for interpretation and guidance. DHCS provided its interpretation in support of GCHP and confirmed GCHP is accurate in requesting VSP, who is a downstream entity, to comply with the Medi-Cal ‘Six-Month Billing Limit’. VSP was able to correct deficiency and comply with the finding. The CAP was closed in 2017. Compliance is currently monitoring (2) open CAPs. Ventura Transit System (VTS) was issued a CAP in 2016 for failing to meet a Security Risk Assessment as described under the Business Associates Agreements (BAA). GCHP accepted the proposal by VTS to hire an independent firm to assist them in the assessment and remediation. GCHP continues to work with VTS and the firm through the remediation process. The second CAP open was issued to Conduent after deficiencies were identified during the annual onsite audit. The CAP will remain open until all deficiencies are closed. Staff is working diligently with each delegate to achieve compliance.


Audits Conducted CY 2017 The table below illustrates all of the audits conducted, closed CY 2017 as well as upcoming in January 2018.

Delegate Name Audit Type Audit Date

Status

Beacon Health Options

2017 Annual Claims

January 2017

Closed

2016 Six month Follow-up Claims

May 2016 Closed

Clinical; QI, UM, RR

February 2017

Closed

Conduent 2017 Annual Claims April 2017 Open CHLA 2017 Credentialing November

2017 Open

Clinicas del Camino Real, Inc.

2017 Annual Claims

November 2017

Open

2017 Credentialing January 2017

Closed


Pending

Clinical; QI, UM, RR December 2017

Open

Ventura County Medical Center


Closed


Pending

Community Memorial Health System


Closed


Pending

Vision Service Plan 2017 Claims December 2017

Open

Ventura Transit Systems

NEMT Annual Audit January 2017

Open

*Pending: Audit(s) are scheduled for a future date and pre-audit letter and material have been sent. **Open: Audit is completed and results are in process.


Privacy Program:

GCHP is required under state and federal laws to notify individuals of any event that compromises the confidentiality of protected health Information (“PHI”) and personally identifiable information (“PII”). Any reported privacy incident related to PHI and PII is investigated and determined if any impermissible access, use, or disclosure of confidential information occurred according to the standards under Privacy Program Policy HI-020 Privacy Incident Reporting, Investigations, and Mitigation and HI-025 Breach Determination and Notification. The following is a summary of the reported privacy incidents and the outcomes of the investigations by the GCHP Compliance Department during for the 2017 reporting period. January through September 2017 Privacy Incident Findings • On average 2.6 incident reports were received a month for the 2017 reporting period.

• 24 privacy incidents were reported, which was an increase of 7 more incidents than the first 3 quarters of 2016.

• A total of 5 privacy incidents were determined to be a breach of unsecured PHI that required notification to members under the HIPAA Breach Notification Rule during the reporting period.

• 22% of the total confirmed privacy incidents for 2017 were breaches of unsecured PHI, which is similar to percentage of breaches for 2016 privacy incidents (16%). (See HIPAA Breach Incidents Compared to Total Incidents Chart)

• Unauthorized Disclosure – Claim Process (57%) is the primary categories for confirmed privacy incidents occurring in 2017. (See Confirmed Privacy Incidents by Incident Category Type Chart)

• Business Associates were the cause of the majority of the confirmed privacy incidents occurring during the reporting period (70%) which is just up from 2016 (60%). (See Privacy Incidents by Source of Privacy Incident Chart)

Privacy Program Continue: Workstation Security Audits (“Audits”) are conducted by the Compliance Department of employee workstations after normal working hours. The Audits are performed to ensure compliance with the standards to safeguard the confidentiality of Protected Health Information (“PHI”) and Confidential Information under GCHP Privacy Policy HI-019 Workstation Safeguards & Security.


The following six “Safeguard Compliance Factors” are reviewed during the Audit: 1. PHI/Confidential Records Not Secured – Workstation drawers/cabinets are checked to

determine if they are locked, and if unlocked, to determine if PHI/Confidential records are stored in the unsecured drawer/cabinet.

2. PHI/Confidential Info On Desktop – Workstation desktop checked to determine if any PHI/Confidential information is left unattended on desktop which should be secured.

3. Passwords Not Secured – Workstation is checked for any apparent passwords that should be secured.

4. Computer Screen Not Locked – Computer is checked to determine if password is locked or user logged off.

5. PHI/Confidential Info in Trash or Recycle Bin – Workstation trash and recycle bins checked for any PHI/Confidential records that should be secured or placed in locked shred bin for destruction.

6. Laptop/Device Not Secured – Workstations with laptops are checked to determine if the laptop is either taken home or secured to docking station along with any portable devices that should be secured.

Key Performance Indicators (KPI) for Audit:

Employee Audit Score 90% Safeguard Factors Audit Score 95%

The following is a summary of the 3rd Quarter 2017 Audit Results for all employees audited:

Total Employee Workstations Audited 108 Total Safeguard Factors

Checked 574

Total Employee Workstations Not Passing the Audit

5

Total Safeguard Factors with Compliance Deficiencies

6

Employee Audit Score 95.4% Safeguard Factors Audit Score 99.0%

Actions Taken in Response to Audits • Full results of each department’s Audit communicated to department management including

any recommendations for improvement. • All employees audited received a Workspace Security Walkthrough Label that either listed

they maintained a “secure workspace” or they were given a notice of which Safeguard Compliance Factor was found out of compliance during the audit for immediate feedback.

• Reoccurring issues found may result in department corrective actions or employee sanctions as necessary.


Privacy Incident Reporting & Investigations Summary

1Page 95 of 153Back to Agenda

Summary of Total Privacy Incidents2016 - 2017

2

0

2

4

6

8

10

12

1Q 2016 2Q 2016 3Q 2016 4Q 2016 1Q 2017 2Q 2017 3Q 2017

Privacy Incidents

Privacy Breaches

2 per. Mov. Avg. (Privacy Incidents)

2 per. Mov. Avg. (Privacy Breaches)


Summary of Privacy Incidents Reported and Investigated in 2017

3

[1] Confirmed Privacy Incidents are incidents that after investigation were determined to be unauthorized access, use, or disclosures of confidential information.[2] Breach determinations and notifications for PHI incidents are required to be conducted within 60 days from the discovery date to notify individuals. Because of this, data reported on privacy breaches may change from month to month.

16%

84%

2016 HIPAA Breach Incidents Compared to Total Confirmed Privacy Incidents

Privacy Breach

Privacy Incident (Non-Breach)

22%

78%

2017 HIPAA Breach Incidents Compared to Total Confirmed Privacy Incidents

Privacy Breach

Privacy Incident (Non-Breach)

Privacy Incidents Reported Incidents Reported to DHCS Confirmed Privacy Incidents

Privacy Incidents Involving PHI

HIPAA Breach Notification Number of Members Notified

January 6 6 6 6 2 2

February 2 2 2 2 0 0

March 3 3 3 3 0 0

April 1 1 1 1 0 0

May 3 3 3 3 1 1

June 2 2 2 1 1 1

July 5 5 5 5 1 1

August 1 1 1 1 0 0

September 1 1 0 0 0 0

2017 Totals 24 24 23 22 5 5


2017 Confirmed Privacy Incidents by Incident Category Type

4

Unauthorized Disclosure

– Email/Fax Error


– Fax Error


– Claim Process


– UM Process


– Mail/Postal Service


– Authorization Required


– Server/Website

Hacking/IT Incident

January 0 0 3 1 0 0 2 0

February 0 0 2 0 0 0 0 0

March 0 0 3 0 0 0 0 0

April 0 0 1 0 0 0 0 0

May 1 0 1 1 0 0 0 0

June 0 0 0 0 1 0 0 1

July 0 0 3 0 2 0 0 0

August 0 1 0 0 0 0 0 0

September 0 0 0 0 0 0 0 0

2017 Totals 1 1 13 2 3 0 2 1

4% 4%

57%9%

13%

9%

4%Privacy Incidents by Type of Incident

Email

Fax

Claim Process

UM Process

Mail

Server/Website

Hacking/IT Incident


2017 Confirmed Privacy Incidents by Source of Privacy Incident

5

GCHP Incidents Business Associate Incidents External Entity

(No BA relationship)

January 1 5 0February 0 2 0March 0 3 0April 0 1 0May 2 1 0June 1 1 0July 2 3 0August 1 0 0September 0 0 0

Totals 7 16 0

32%

60%

8%

2016 Privacy Incidents by Source of Incident

GCHP

Business Associate

External Entity

30%

70%

0%

2017 Privacy Incidents by Source of Incident

GCHP

Business Associate

External Entity


Workstation Privacy Safeguards Audit Program

6Page 100 of 153Back to Agenda

Workstation Privacy Safeguards Audit Program

7

Workstation Security Audits (“Audits”) are conducted by the Compliance Department of employee workstations after normal working hours. The Audits are performed to ensure compliance with the standards to safeguard the confidentiality of Protected Health Information (“PHI”) and Confidential Information under GCHP Privacy Policy HI-019 Workstation Safeguards & Security. The following six “Safeguard Compliance Factors” are reviewed during the Audit for each workstation: 1. PHI/Confidential Records Not Secured 2. PHI/Confidential Info On Desktop 3. Passwords Not Secured 4. Computer Screen Not Locked 5. PHI/Confidential Info in Trash or Recycle Bin

6. Laptop/Device Not Secured

Employee Audit Score 90% Safeguard Factors Audit Score 95%

Key Performance Indicators (KPI) for Audit:


Workstation Audit Summary Results 2016 -2017

8

1st Q 2016 2nd Q 2016 3rd Q 2016 4th Q 2017 1st Q 2017 2nd Q 2017 3rd Q 2017

Employee Audit Score 95.1% 93.2% 84.1% 93.0% 98.1% 90.6% 95.4%

Safeguard Factors Audit Score

98.6% 98.7% 96.6% 98.7% 99.3% 98.1% 99.0%

95.1%93.2%

84.1%

93.0%

98.1%

90.6%

95.4%98.6% 98.7%

96.6%98.7% 99.3% 98.1% 99.0%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

1st Q 2016 2nd Q 2016 3rd Q 2016 4th Q 2016 1st Q 2017 2nd Q 2017 3rd Q 2017

Employees Audit Score


Safeguard Factor Score

Employee Audit ScoreKPI 90%


Summary of Workstation Audit Factors3rd Quarter 2017 Audit Results

9

Audit Factor Total Factors Audited Total Factors Out of Compliance


Factor 1PHI/Confidential Records Not Secured 108 1 99.1%

Factor 2PHI/Confidential Info on Desktop 108 2 98.1%

Factor 3Passwords Not Secured 108 1 99.1%

Factor 4Computer Screen Not Locked 108 0 100%

Factor 5PHI/Confidential Info in Trash or Recycle Bin 108 0 100%

Factor 6Laptop/Device Not Secured 34 2 94.1%

16.7%

33.3%16.7%

0.0%0.0%

33.3%

Total Factors Out of ComplianceFactor1Factor2Factor3Factor4Factor5Factor6


AGENDA ITEM NO. 15 TO: Ventura County Medi-Cal Managed Care Commission FROM: Ruth Watson, Chief Operating Officer DATE: December 4, 2017 SUBJECT: Chief Operating Officer Update OPERATIONS UPDATE Membership Update Gold Coast Health Plan (GCHP) membership is a product of Ventura County residents who are eligible for Medi-Cal and who choose to sign up for our plan. Membership is fluid, as people must re-determine each year, move in and out of the county, become ineligible based on income or move to Medi-Cal fee for service. As of November 1, 2017, Gold Coast Health Plan’s (GCHP’s) total membership was 200,584. The Plan experienced a net loss of 1,590 members over the previous month. We attribute the loss to the following potential impacts:

• Lack of redeterminations; • Movement of members out of the county; • Increases to income rendering member ineligible for plan participation.

AB 85 Auto Assignment- State Assembly Bill 85 (AB 85) requires that the Plan assign 50% of new Adult Expansion (AE) members who have not chosen a PCP within 30-days of enrollment to the County Public Hospital System, VCMC. In the month of November, GCHP assigned 401 new members to VCMC, while the remaining 402 new members were assigned to providers in compliance with the VCMMCC Auto Assignment policy (MS-005). VCMC has 29,959 AE members assigned as of November 1, 2017. VCMC’s target enrollment, as established by DHCS, is 65,765 and is currently at 45.56% of the target. Monthly Adult Expansion (AE) Membership Lookback (by aid code) L1 M1 7U 7W 7S Total Nov 17 402 55,311 22 7 78 55,820 Oct 17 421 55,993 25 7 82 56,528 Sep 17 432 56,042 32 7 84 56,597 Aug 17 447 56,028 58 14 87 56,634 Jul 17 464 55,407 80 30 94 56,075


Jun 17 484 55,462 83 31 91 56,151 May 17 505 55,331 92 35 113 56,076 Apr 17 520 55,333 94 44 163 56,154 Mar 17 560 55,539 100 48 210 56,457 Feb 17 590 55,667 113 55 243 56,668 Jan 17 646 55,551 141 50 203 56,591 Dec 16 695 55,820 521 123 240 57,399

Member Orientation Meetings One Hundred and thirty-five (135) total members (83 English, 23 Spanish) attended Member Orientation meetings between January and October 2017. Of the 135 members, 65 indicated they learned about the meeting through the informational flyer included in each new member packet. Other methods of notification included:

• Website • TCRC • HSA • MICOP

Claims Update Claims Inventory represents the number of claims received during the month. Claims Inventory for October is 182,684. This equates to a Days Receipt on Hand (DROH) of 2.436 days in October compared to a DROH maximum goal of 5 days. October is reflecting a decrease in DROH over the previous month. GCHP received an average of 8,304 claims per day in October. Monthly Claims Receipts

Month Total Monthly Claims Received

Average Daily Claims Receipts

October 2017 182,684 8,304 September 2017 174,104 8,705 August 2017 206,314 8,970 July 2017 167,905 8,395 June 2017 183,581 8,345 May 2017 200,595 9,118 April 2017 164,613 8,231 March 2017 208,407 9,061 February 2017 171,343 9,018 January 2017 168,660 8,433 December 2016 190,686 9,080 November 2016 170,209 8,510


Claims Processing Results – Conduent has several Service Level Agreements (SLAs) in place with GCHP to ensure that claims processed meet the minimum state and generally accepted service levels for claim processing. GCHP measures three (3) SLAs for claim processing:

• Claims Turnaround Time (TAT) - The number of days needed to process a claim from date of receipt to date of determination. The target is determination of 90% of original clean claims processed within 30 calendar days of receipt.

• Financial Claims Processing Accuracy- Percentage of correct payments against the total payments made in a month. The target is ≥ 98%

• Procedural Claims Processing Accuracy- The number of claims without any procedural errors (non-financial) against the total number of claims processed. The target is ≥ 97%.

Conduent met all claim SLAs for the month of October. Monthly Claims SLA Performance Month: October Service Level Agreement Expected Outcome Actual Outcome

Claim Turnaround Time 90% 99.20% Financial Claims Processing Accuracy 98% 99.90% Procedural Claim Processing Accuracy 97% 99.86%

Claims Denials rate is 13.87% of total volume, which is within industry expectations. Top Claims Denial Reasons

• Service is included in Monthly Capitation per contract with provider • Duplicate line item • Primary Carrier EOB Required • Charges incurred after term date • Denied base on system edit • Services are the financial responsibility of Clinicas


Encounter Update Encounter Data Quality Summary– GCHP collects monthly encounter data, which we submit to DHCS. These data determine, in part, the rates GCHP receives from the state to manage member care. GCHP measures three (3) aspects of encounter data on a monthly and quarterly basis:

• Submitted – the total number of encounter records submitted to GCHP each month. • Errors – the total number of encounters submitted with invalid data such as

formatting, errors, utilization of out of date coding or missing data. • Percent of Errors – the number of errors divided by the total number of encounters

submitted.

Monthly Encounter Data Month: October Encounter Type Submitted Errors % of Errors Professional 92,666 1,721 1.9% Institutional 70,506 605 0.9% Pharmacy 143,621 2,918 2.0% Total 306,793 5,244 1.7%

Reasons for the errors include:

• Not Valid code • Duplicate encounter • No Medi-Cal eligibility • Procedure date • Admission date

Note: SLAs do not apply to encounter data. Call Center Update Call Center Results – Conduent is responsible for taking level one calls from members and providers. The volumes reported reflect only Conduent call data. Additional calls are taken by the GCHP member services team, which includes calls routed from Conduent, considered escalated or second level calls, calls from providers and members directly to the GCHP member services team and any calls to members or providers who request a call back from the GCHP member services team. Conduent has three (3) call queues: provider, member (English), member (Spanish). GCHP monitors and reports on two (2) specific areas that help identify the Conduent Call Center work effort:


• Call Volume – Call volume measures the number of calls taken in a month’s time. October call volume was 12,950.

• Average Call Length – Call length measures the amount of time a call center

representative spends on a call with a member or provider. Call length is a function of the call type and may be shorter or longer depending on the type of call and type of caller. GCHP measures the average call length only as an indicator of how long the call center representatives are spending with our callers. October average call length was 6.54 minutes per call.

GCHP currently has three (3) SLAs that measure Conduent’s call center efficacy on a monthly basis. Conduent met all one (1) of three (3) targets in the month of October.

• Average Speed to Answer (ASA) – The number of seconds a caller waits in a queue

until the call is answered by a call center representative. o Target – <30 seconds

• Abandonment Rate – Abandonment rate measures the percentage of calls disconnected by a caller prior to the call being answered by a Customer Service Representative.

o Target - ≤ 5%. • Call Center Call Quality – Conduent and GCHP staff work collaboratively to calibrate

selected calls each week and use a standardized scoring tool to measure the percentage of calls answered accurately.

o Target - 95% or higher. Monthly SLA Performance Month: October Service Level Agreement Expected Outcome Actual Outcome Average Speed To Answer <30 seconds 203 sec Abandonment Rate <5% 10.86% Call Center Call Quality >95% 95.06%

Average Speed to Answer exceeded 30 seconds in the month of October. Conduent expressed the following as contributing factors to the missed SLAs

• A 40% decrease in staff coupled with a hiring freeze; • Increased call volume; • Increased talk time related to member call due to additional information requirements;

GCHP is working closely with Conduent leadership regarding the impacts to the SLAs and has identified staffing attrition and increased talk time as root causes. Conduent has hired and trained five new agents, who are taking calls. Performance levels for these trainees will be low until they complete their training period. During this training period, Conduent has


taken an “all hands on deck” approach to engage supervisors, trainers and additional internal resources to take calls in an effort to insure that member and provider needs are met. GCHP will continue to work with Conduent to improve Call Center performance for quality, timeliness and accuracy. Grievance and Appeals Update Conduent is responsible for responding to level one Provider Dispute Resolution (PDR) requests when providers disagree with the manner in which a claim was processed. GCHP manages all first level member appeals should a member submit an issue regarding a claim payment or denial, provider access or any other situation the member has experienced. Should the member or provider choose to continue to a second level action, those requests are resolved by GCHP. The Grievance and Appeals team at GCHP also processes any clinical appeals in conjunction with the GCHP Health Services team. GCHP received two (2) clinical appeals for the month of September. Both of the clinical appeals were overturned. During September, GCHP attended four (4) State Fair Hearing cases. One (1) was withdrawn, and three (3) were dismissed. GCHP received 23 member grievances and 233 provider grievances in the month of September. Member grievances equate to 0.11 grievances per 1,000 members, with a slight increase in the last three months. Monthly Member Grievances

Note: G&A results are reported 2 months in arrears GCHP received 23 Quality of Care member grievances, which consisted of the following issues:

• Delay of Care • Poor provider/staff attitude

Month: September Type of Member Grievances Number of Grievances Accessibility 1 Benefits 3 Denials/Refusals 1 Quality of Care 16 Quality of Service 2 Total Member Grievances 23


NETWORK OPERATIONS UPDATE OCTOBER 2017

A. PROVIDER SITE VISIT RESULTS

• Orientations: 14 new provider orientations were conducted by GCHP Provider

Relations Staff over the last 3 months. This figure is up approximately 33% from the previous quarter.

• 12 Physicians declined orientation during this reporting period due to joining an

established contracted group with GCHP. Established groups such as delegated providers have participated in previous orientations; they are familiar with GCHP policies and procedures and have the staff and capability to perform the orientation function on their own.

• Site Visits: 33 provider site visits were completed by Network Operations-Provider Relations staff. This figure is up approximately 167% from the previous quarter as we have re-filled a provider relations position and returned to our standard visit goal of 40 visits per month.


B. KEY PROJECTS:

1. MANAGED CARE PROVIDER DATA IMPROVEMENT PROJECT (MCPDIP) 274- UPDATE

• Three (3) new enhancements provided by the state will be put into production for the

February 2018 submission to the state. We are on schedule to meet this timeline.

2. SB 137 PROVIDER DIRECTORIES • Network Operations has completed all SB 137 updates to the printed directory for the

upcoming 12/30 pull.

3. PROVIDER NETWORK DATA BASE & CREDENTIALING SYSTEM RFP

The Plan has conducted a Request for Proposal (RFP) and is in the process of vendor selection for the purchase and implementation of a tool to improve the management of provider data, contracting and credentialing functions. The Plan’s existing provider database management (PDM) tool is an in-house solution with limited functionality and scalability requiring significant manual intervention. The vendor tool will provide automation to improve data base accuracy, create process efficiency and support state and federal regulatory requirements. Staff will present a request for approval to the Commission by the 3rd quarter of Fiscal Year(FY) 2018. Current procurement status is as follows:

o Determination of high level pricing estimates o Statement of work o Business requirements development o Contract review

C. PROVIDER ADDS & TERMINATIONS- September 15, 2017- October 31, 2017

Provider Adds: 50

• Hospitals: 0

• Providers: 45 - PCPs & Mid-levels: 14 - Specialists 27 - Hospitalists: 4

• Ancillary: 5 - Occupational Therapy: 1


- Physical Therapy: 1 - Radiology: 2 - Speech Therapy:1

Provider Terms: 15

• Ambulatory Surgery Ctrs:1 Impact: None. 8 ASC’s contracted Term due to failure to submit re-credentialing documentation.

• Hospitalist: 1 Impact: None. This provider terms was from a tertiary

center in LA.

• PCP’s and Mid-Levels: 5 Impact: Small. Terms mainly due to provider terms from

3 main clinics.170 FP’s, 48 peds and 36 IM PCP’s remain actively contracted. Number excludes mid-levels. • Specialists: 8 Impact: None: Terms due to provider clean-up and

Physicians re-locating.

D. CONTRACTING AND PROVIDER RELATIONS:

• Finalizing contracts with: - 1 major orthopedic provider group in county - 2 urgent care centers in county - 1 Ambulatory Surgery Center

• Joint Operations meetings with:

- Home Health providers - CMH - VCMC (12/1) - Clinicas del Camino Real

• Process Improvement Initiatives

- Better mapping with our geo-access reporting system to meet new regulatory access requirements

- Coordinated meetings with operations to determine claims root cause issues to reduce claims adjustments and interest payments


E. VALUE BASED INITIATIVES:

• Camarillo Health Care District Transition of Care Program: Program initiated 8/1/2017 The pilot is designed to enhance 30 to 90 day care transition interventions to members discharged from Community Memorial Health System (“CMHS”). Each member will receive an inpatient visit from a transitional health coach, one to three home visits and weekly check-in calls following each visit. Additionally, pilot staff will collaborate with and offer support to the home health agencies and other community health partners involved in the care of the member post discharge. It is the goal of this this pilot to keep the targeted population of members out of the emergency room and help avoid hospital re-admissions when possible. This pilot allows both Gold Coast Health Plan and provider to address the broader aspect of a member’s care, not only for medical conditions, but also for day-to-day improvement of functional abilities, cognitive status and social supports that will allow a member to thrive at home and in the community.

• Signed new Amendment for renewal of Asthma Pilot Program with County of Ventura. Effective 10/1/2017

This initiative is designed to manage asthma for Members identified as high risk, so the member or parents/caregivers can reduce the frequency of uncontrolled asthma attacks, avoid unnecessary trips to the emergency room, and reduce the number of hospital admissions for a member at high risk for uncontrolled asthma. It is the intent of this pilot program to provide adult and pediatric Members and caregivers with this knowledge through an in-home assessment and asthma education program for High Risk Asthma Members and parents/caregivers. Given the success of the initial pilot the program has been expanded to include up to an additional 10 members or 60 total Members.

• Working with Ventura County Medical Center (VCMC) to implement CA 1115 Waiver- Public Hospital Redesign and Incentives in Medi-Cal PRIME project and metrics protocols.

- Five (5) year grant by DHCS - DHCS has committed that 60% of all Medi-Cal managed care beneficiaries will

receive a portion of their care through systems paid under alternative payment methodologies by the end of the demonstration period in 2020.

- Evaluating key target metrics - Contract discussions in process


Total Membership as of Nov 1, 2017 – 200,584*New Members Added Since January 2014 – 82,072

GCHP Membership

175,000180,000185,000190,000195,000200,000205,000210,000

Dec‐16 Jan‐17 Feb‐17 Mar‐17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17

GCHP Membership Trend Dec 2016 ‐ Nov 2017

Dec‐16 Jan‐17 Feb‐17 Mar‐17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17Active Membership 206,252 204,529 204,417 203,243 202,338 201,514 201,455 200,903 202,670 202,630 202,174 200,584

‐500

500

1,500

2,500

1‐Dec 1‐Jan 1‐Feb 1‐Mar 1‐Apr 1‐May 1‐Jun 1‐Jul 1‐Aug 1‐Sep 1‐Oct 1‐Nov

Change from Prior Month


Membership Growth402

55,311

22

7

78

26,252

GCHP New Membership Breakdown

L1 ‐ Low Income Health Plan ‐ 0.49%

M1 ‐ Medi‐Cal Expansion ‐ 67.39%

7U ‐ CalFresh Adults ‐ 0.03%

7W ‐ CalFresh Children ‐ 0.01%

7S ‐ Parents of 7Ws ‐ 0.10%

Traditional Medi‐Cal ‐ 31.99%


The 30 Day Turnaround Time (TAT) was compliant with the expected service level. 99.05% of clean claims were processed timely with the minimum requirement at 90%.

Ending Inventory was 20,230 which equates to a Days Receipt on Hand (DROH) of 2.44 days vs a target DROH ≤ 5 days

Service Level Agreements (SLAs) for Financial Accuracy (99.86%) and Procedural Accuracy (99.90%) were both met in October

GCHP Claims Metrics –October 2017

0

10,000

20,000

30,000

40,000

50,000

60,000

Ending Inventory

84%

86%

88%

90%

92%

94%

96%

98%

100%

Claims Processing Turnaround TimeSLA = 90% of clean claims processed w/i 30 calendar

days

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Financial Procedural

Financial and Procedural AccuracySLA = 98% Financial, 97% Procedural


GCHP Grievance & Appeals Metrics – Sept. 2017 GCHP received 23 member grievances

(0.11 grievances per 1,000 members) and 233 provider grievances during September 2017

GCHP’s 12-month average for total grievances is 178 19 member grievances per month 196 provider grievances per month

Oct‐16 Nov‐16 Dec‐16 Jan‐17 Feb‐17 Mar‐

17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐

17 Sep‐17 12‐moAvg

# of Grievance per 1000 Members 0.06 0.03 0.08 0.06 0.07 0.09 0.05 0.07 0.09 0.14 0.17 0.11 0.08

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18Member Grievance per 1000 Members

Oct‐16 Nov‐16 Dec‐16 Jan‐17 Feb‐17 Mar‐17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 12‐mo AvgMembership Count 207,188 206,780 206,252 204,529 203,243 201,514 202,338 201,514 201,455 200,903 202,670 206,672 186,532Total Member Grievances Filed 12 7 16 13 15 19 10 15 19 29 34 23 16# of Grievance per 1000 Members 0.06 0.03 0.08 0.06 0.07 0.09 0.05 0.07 0.09 0.14 0.17 0.11 0.08

Oct‐16

Nov‐16

Dec‐16

Jan‐17

Feb‐17

Mar‐17

Apr‐17

May‐17

Jun‐17 Jul‐17 Aug‐

17Sep‐17

12‐moAvg

Member 12 7 16 13 15 19 10 15 19 29 34 23 18Provider 176 118 166 194 157 158 168 177 253 172 166 233 178Combined 188 125 182 207 172 177 178 192 272 201 200 256 196

0

50

100

150

200

250

300

Total Grievances per Month


GCHP Grievance & Appeals Metrics – September 2017 GCHP had 2 clinical appeals in Sept;

The 2 reported were Overturned TAT for grievance acknowledgement was at

95% TAT for grievance resolution was at 98% TAT for appeal acknowledgement and

resolution were compliant at 100%. 4 State Fair Hearings were reported in Sept

2017, 1 was Withdrawn and 3 Dismissed

0

1

2

3

4

5

6

7

8

9

10

Upheld Overturned Withdrawn Total # of Appeals

Total Clinical Appeals per Month

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct‐16 Nov‐16 Dec‐16 Jan‐17 Feb‐17 Mar‐17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 12‐mo Avg

Grievance Acknowledgement Grievance Resolution Appeal Acknowledgement Appeal Resolution

G&A Acknowledgement and Resolution TATSLA = Acknowledgement - 100% w/i 5 days, Resolution - 100% w/i 30 days


Call volume remained above 10,000 during the month; GCHP received 12,950 calls during October

Service Level Agreements (SLA) for ASA (202.8 seconds vs the contractual requirement of ≤ 30 seconds) and Abandonment Rate (10.86% vs the contractual requirement of ≤ 5%) ASA and Abandonment Rate were not met for October

GCHP Call Center Metrics –Oct 2017

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Member Provider Spanish Combined

Call Center Volume

0

10

20

30

40

50

60

70

80

90

100


Average Speed of Answer (ASA)(SLA = 30 seconds or less)

0%

1%

2%

3%

4%

5%

6%


Abandonment Rate(SLA = 5% or less)


Gold Coast Health PlanWeekly Claims Processing Dashobard

July 5, 2017 ‐ Oct 25,2017

07/05/17 07/12/17 07/19/17 07/26/17 08/02/17 08/09/17 08/16/17 08/23/17 08/30/17 09/06/17 09/17/17 09/20/17 09/27/17 10/04/17 10/11/17 10/18/17 10/25/17Corrective Action Plan TrackingCAP Reference3c ‐ Percentage of Claims Denied (1) 12.07% 14.99% 12.08% 12.64% 11.85% 13.14% 12.64% 15.25% 16.44% 12.56% 13.65% 15.81% 12.86% 13.67% 12.86% 13.30% 12.81%3e ‐ Number of Claim Adjustments (2) 586 1,000 1,041 1,035 942 1,028 1,411 1,375 1,110 901 1,195 971 918 1,368 1,880 1,011 9683f ‐ Number of Claims Processing FTEs (3) 44 44 44 43 43 43 42 42 41 40 40 40 39 42 40 39 403g ‐ Auto Adjudication Rate (4) 50.56% 40.10% 57.45% 52.78% 55.12% 53.40% 49.71% 53.04% 50.83% 50.26% 44.33% 55.60% 54.42% 49.34% 52.57% 55.99% 46.36%3g ‐ Auto Adjudication Rate including Autobot (4) 69.23% 58.20% 71.53% 68.65% 67.80% 66.86% 73.62% 68.91% 63.76% 65.97% 59.56% 68.26% 68.50% 66.08% 67.44% 70.72% 62.00%4a ‐ Number of Items in ACS Refund Check Queue (5) 33 69 8 27 0 0 6 11 0 0 16 35 17 33 17 1 04a ‐ Number of Items in ACS Refund Check Queue > 20 Days TAT 3 1 0 0 0 0 1 0 0 0 0 0 0 1 0 1 04a ‐ Number of Items in Non‐Indexed Refund Check Queue (5) 25 37 55 43 37 65 89 62 118 181 85 22 27 17 13 5 68

Claim Receipts Total Claim Receipts 35,511 39,366 42,239 40,343 42,283 55,122 40,934 41,920 41,661 40,668 35,172 47,804 43,281 42,922 40,056 46,543 38,645

Average Claims Receipts (6) 8,539 8,208 7,978 7,960 7,873 8,212 8,999 8,934 9,013 8,982 8,259 7,971 8,265 8,346 8,459 8,703 8,640

Mailroom Inventory on Hand Items in EDGE to be worked (8) 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 Claims with Front‐end Errors (9) 412 571 757 865 722 1,046 544 546 667 1,009 700 834 596 753 531 671 541

IKA Inventory on Hand Pended Inventory 22,783 22,572 24,178 25,789 29,663 39,049 34,965 36,069 33,222 31,232 27,763 30,413 32,261 32,053 31,166 27,565 21,341

Working Inventory (10) 23,204 23,152 24,944 26,663 30,394 40,104 35,518 36,624 33,898 32,250 28,472 31,256 32,866 32,815 31,706 28,245 21,891 Claims Ready to Pay (11) 1,284 7,216 4,229 5,001 2,626 6,209 3,653 3,624 3,220 3,603 4,598 4,756 3,851 4,899 3,271 3,126 3,875

Current Inventory 24,488 30,368 29,173 31,664 33,020 46,313 39,171 40,248 37,118 35,853 33,070 36,012 36,717 37,714 34,977 31,371 25,766 DROH Working Inventory (10, 12) 2.7 2.8 3.1 3.3 3.9 4.9 3.9 4.1 3.8 3.6 3.4 3.9 4.0 3.9 3.7 3.2 2.5

DROH Current Inventory (12) 2.9 3.7 3.7 4.0 4.2 5.6 4.4 4.5 4.1 4.0 4.0 4.5 4.4 4.5 4.1 3.6 3.0

Clean Claims Aging (7) 31 to 60 Days 1,032 1,045 1,056 992 983 1,005 1,035 1,086 1,184 1,228 1,221 1,259 948 858 934 869 882 61 to 90 Days 0 0 0 0 0 0 0 3 2 1 3 0 0 1 1 1 2

90+ Days 1 1 0 1 1 1 1 2 2 1 5 4 2 3 2 1 3 Total Clean Claims Aged > 30 Days 1033 1046 1056 993 984 1006 1036 1091 1188 1230 1229 1263 950 862 937 871 887

Contested Claims Aging (7) 0 to 30 Days 451 330 323 343 415 419 290 264 289 317 348 280 269 329 292 612 408

31 to 60 Days 8 2 10 9 4 2 4 9 6 8 5 7 3 2 2 3 3 61 to 90 Days 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1

90+ Days 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Aging of Total Contested Claims 460 333 334 353 420 422 295 274 296 326 354 288 273 332 295 617 413

Productivity EDI Claims Rejected 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1297 1539 Deleted Claims (13) 897 700 885 1,061 1,174 1,033 978 818 946 1,028 821 826 1,176 904 764 938 1,028

Denied Claims 5,092 5,175 5,065 4,845 4,786 5,276 5,990 6,228 7,138 4,983 5,075 7,348 5,501 5,504 5,356 5,738 5,233 Allowed Claims 37,082 29,348 36,860 33,497 35,589 34,875 41,413 34,622 36,273 34,690 32,109 39,116 37,286 34,761 36,301 37,396 35,610

Actual Weekly Production (14) 42,174 34,523 41,925 38,342 40,375 40,151 47,403 40,850 43,411 39,673 37,184 46,464 42,787 40,265 41,657 43,134 40,843 Total Weekly Production (15) 43,072 35,223 42,811 39,403 41,549 41,184 48,381 41,668 44,357 40,701 38,005 47,290 43,963 41,169 42,421 45,369 43,410

Average Daily Production (16) 8,646 8,446 8,400 8,138 8,085 8,016 8,197 8,497 8,570 8,809 8,625 8,284 8,574 8,530 8,586 8,676 8,500 DWOH Working Inventory (10, 17) 2.7 2.7 3.0 3.3 3.8 5.0 4.3 4.3 4.0 3.7 3.3 3.8 3.8 3.8 3.7 3.3 2.6

DWOH Current Inventory (17) 2.8 3.6 3.5 3.9 4.1 5.8 4.8 4.7 4.3 4.1 3.8 4.3 4.3 4.4 4.1 3.6 3.0

111/30/2017Page 120 of 153Back to Agenda

Gold Coast Health PlanWeekly Claims Processing Dashobard

July 5, 2017 ‐ Oct 25,2017

Notes:(1) Percentage of Claims Denied is calculated as the number of Denied claims divided by Actual Weekly Production (total denied and allowed claims for the week)(2) Number of Claims Payment Adjustments processed in the ika claims system as reported by Xerox on the claims Financial Transaction Summary Report(3) Number of Xerox claims processing FTEs as reported in the Roster Report provided by Xerox.(4) Auto Adjudication Rate calculated from "Inventory Tracking to Date" using week to date productivity totals as of Wednesday of each week. Auto Adjudication Rate including Autobot includes claims processed with Autobot, which allows for systematic processing of claims.(5) Number of Items in Refund Queue reflects the number reported by Xerox in the "Queue Aging Report" as of Wednesday of each week(6) Average Claims Receipts is calculated as the number of receipts in the past four weeks divided by 20 days.(7) Reflects the aging reported by Xerox on the "Claims Aging Report" as of Wednesday of each week.(8) Count of items still in EDGE process that have not been loaded into KWIK or ika.(9) Includes claims that need additional research to determine whether or not they can be loaded into ika(10) Working inventory includes mailroom inventory on hand and pending claims inventory. It does not include claims that have been adjudicated and have a status of ready to pay(11) Claims Ready to Pay have been adjudicated and are ready for payment stream.(12) Days Receipt on Hand (DROH) is calculated as the Working/Current Inventory divided by the Average Claim Receipts.(13) Deleted claims have been replaced by a new claim. Deleted claims are still in ika; however, the status has been changed to deleted so the new claim can be worked(14) Actual Weekly Production is the total number of Denied and Allowed claims.(15) Total Weekly Production includes Deleted, Denied and Allowed claims.(16) Average Daily Production is calculated as the total production in the past four weeks divided by 20 days(17) Days Work on Hand (DWOH) is calculated as the Working/Current Inventory divided by the Average Daily Production.

Sources: Claims Financial Transaction Summary Report, GCHP Inventory Tracking to Date, Claims Aging Report, Queue Aging Report, Xerox Roster Report

211/30/2017Page 121 of 153Back to Agenda

AGENDA ITEM NO. 16 TO: Ventura County Medi-Cal Managed Care Commission FROM: Lyndon Turner, Interim Chief Financial Officer DATE: December 4, 2017 SUBJECT: Internal Audit Updates: AB85 Auto-Assignment; Human Resources and

Payroll; and Accounts Payable

HANDOUT WILL BE AVAILABLE AT THE MEETING


AGENDA ITEM NO. 17

TO: Ventura County Medi-Cal Managed Care Commission FROM: Nancy Wharfield, MD, Chief Medical Officer DATE: December 4, 2017 SUBJECT: Chief Medical Officer Update HEALTH SERVICES UPDATE Utilization data in the Health Services quarterly update to the Commission is based on paid claims compiled by date of service and is lagged by 3 months to allow for partial run out of claims data. Claims data is complete at approximately 6 months. While incomplete, a 3 month lagged snapshot allows us to see an estimate of utilization without waiting for a more complete 6-month report. Administrative days are included in these calculations. Dual eligible members, Skilled Nursing Facility (SNF), and Long Term Care (LTC) data is not included in this presentation. UTILIZATION SUMMARY Inpatient utilization metrics for CYTD 2017 are similar to CY 2016. BED DAYS: Bed days/1000 members have declined by about 43%, from Plan’s inception in 2011 through CY 2016. Bed days/1000 for CYTD 2017 are unchanged from CY2016 (207). The proportion of bed days utilized by AE members increased slightly (39% to 45%) in a year-to-year comparison of June 2016 to June 2017. Bed days/1000 for SPD members for CYTD 2017 are also similar to CY 2016 (1006 v. 999). While the rate of bed days for SPD members is high, it does not have a strong effect on the overall plan rate of bed days per 1,000 members because SPD is such a small portion of our membership (5%). Bed days/1000 benchmark: While there is no Medi-Cal Managed Care Dashboard report of bed days/1000 members, review of available published data from other managed care plans averages 238/1000 members. There is variability of reporting of Administrative Days among managed care plans. AVERAGE LENGTH OF STAY: Average length of stay for CY2016 was 4.2. Average length of stay for CYTD 2017 is 4.0. Average length of stay benchmark: While there is no Medi-Cal Managed Care Dashboard report of bed days/1000 members, review of available published data from other managed


care plans averages 5. There is variability in reporting of Administrative Days among managed care plans. ADMITS/ 1000: Admits/1000 for CY2016 were 50/1000 members. Admits/1000 for CYTD2017 are 51/1000 members. Admits/1000 SPD members are 195 for CYTD 2017. Admits/1000 benchmark: The DHCS average for admits/1000 members is 54. The DHCS average admits/1000 for SPD members is 458. This variation between GCHP and DCHS may be explained by the relative youth of GCHP SPD members versus DHCS SPD members. (Only 33% of GCHP SPD members are age 40 – 64 years versus 42% for the DHCS SPD population. ED UTILIZATION/1000: ED utilization/1000 members typically peaks in January or February. CYTD 2017 ED utilization/1000 members increased from CY2016 (478 v. 447). For June 2017, the Family aid code group continues to show the highest ED utilization (46%) followed by AE (35%). This utilization pattern is essentially unchanged from CY 2016. ED utilization/1000 for SPD members for CYTD 2017 is also increased from CY 2016 (852 v. 802). This represents approximately 10% of ED utilization. ED utilization benchmark: The HEDIS mean for managed Medicaid plans for ED utilization/1000 members is 587. The March 2017 Medi-Cal Managed Care Performance Dashboard reported average SPD ED utilization to be 1065/1000 members.



TOP ADMITTING DIAGNOSES Pregnancy related diagnoses and sepsis continued to dominate top admitting diagnoses for CY 2016 and CYTD 2017. For members admitted with a primary diagnosis of sepsis, secondary diagnoses were cancer, heart disease, liver or renal transplant, and diabetes were secondary diagnoses.


READMISSION RATE The quarterly readmission rate has declined from a recent peak in Q2 of 2016 (13.6%) to an average of 12.6% for CYTD 2017. Readmission rate benchmark: The DHCS Managed Care weighted average for readmission is 14.5%.

CLINICAL GRIEVANCES AND APPEALS For CY2016, there were an average of 30 grievances/ quarter. The average number of clinical grievances/quarter for CYTD 2017 has increased to 47. Most grievances (85%) were characterized as quality of care issues. Only 2% of grievances were characterized as access issues for CY 2016. Access issues comprised 3% of grievances for Q3 2017.

QTR Grievance Total

Appeals Total Upheld Partial

Overturn Overturned Withdrawn Dismissed

2016

Q1 26 9 3 (34%) - 4 (44%) 1 (11%) 1 (11%)

Q2 32 9 7 (78%) - 2 (22%) - -

Q3 33 24 7 (29%) - 14 (58%) 1 (5%) -

Q4 27 21* 7 (33%) - 6 (29%) 1 (5%) -

2017

Q1 34 15 6 (40%) - 8 (53%) 1 (7%) -

Q2 40 17 9 (54%) - 4 (23%) 4 (23%) -

Q3 66 17 9 (53%) - 6 (35%) 2 (12%) -

*Q4 2016 total appeals includes 7 (33%) in progress.


DENIAL RATE Denial rate is calculated by dividing all not medically necessary denials by all requests for service. Denials for duplicate requests, member ineligibility, rescinded requests, other health coverage, or CCS approved case are not included in this calculation. The denial rate has ranged between 2.7% and 4.5% since 2013. The average denial rate for CY 2016 was 3.9% and for CYTD 2017 is 3.4%.


HEALTH EDUCATION UPDATE Summary Gold Coast Health Plan (GCHP) continues to participate in community education and outreach activities throughout the county. The health education and outreach teams maintain a positive presence in the community by working with various county public health departments, community-based organizations, schools, senior centers, faith-based centers and social service agencies. Outreach Events Below is a list of activities during the month of October:

October 2017 List of Activities 10/5/2017 College Health Fair / Ama tu Vida, Oxnard 10/6/2017 Sharing the Harvest/Produce Giveaway, Santa Paula 10/7/2017 City of Oxnard 22nd Multicultural Festival, Plaza Park, Oxnard 10/10/2017 Baby Steps Program, hosted by Ventura County Medical Center, Ventura 10/14/2017 Tooth Fairy 5k/10k/1k Kids Fun Run & Community Health Expo, hosted by The Free

Cljnic of Simi Valley 10/14/2017 Oxnard Revival Center Community Resource Fair 3rd Annual “My Community First, Rio

Real Elementary School, Oxnard 10/15/2017 SAI BABA Medical Camp, Our Lady of Guadalupe Church, Oxnard 10/15/2017 Binational Health Week “Health Unites Us All”, Our Lady of Guadalupe Church, S.Paula 10/17/2017 Baby Steps Program, hosted by Santa Paula Hospital 10/18/2017 Monthly Food Distribution Program & Health Services, hosted by Westpark Community

Center 10/21/2017 2017 Senior Summit, Cal State Channel Islands, Camarillo 10/24/2017 Ventura College Health Fair, Ventura 10/26/2017 Community Market Produce Giveaway, hosted by Moorpark/Simi Valley Neighborhood

for Family Learning, Moorpark 10/26/2017 Community Market Produce Giveaway, hosted by Moorpark/Simi Valley Neighborhood

for Family Learning, Simi Valley


Schools and YouthGroups SPD Colleges Food Distribution General

PopulationTotal 1 1 2 4 6

0

1

2

3

4

5

6

7

Total Member Outreach EventsOctober 2017 (N=14)

Community Baby StepsProgram

ResourceFair Cultural Food

DistributionGeneralEvent Health Fair

Total 22 66 92 102 145 199 334

22

6692 102

145

199

334

0

50

100

150

200

250

300

350

400

Total ParticipantsOctober 2017 (N=960)


Health Education The Health Education Department continues to educate members throughout the community on various health topics. During the month of October, a total of 12 Health Education classes were conducted on the following topics: breast cancer awareness, healthy living, nutrition and physical activity. GCHP health navigators will call members after an event if they have completed a health education referral and are active GCHP members. Below is a list of classes during the month of October:

October 2017 List of Classes # Participants 10/3/2017 Healthy Living, Fillmore Active Adult Center 3 10/4/2017 Healthy Living Workshop, Housing Authority of the City of San

Buenaventura 7

10/5/2017 Healthy Living Workshop, Housing Authority of the City of San Buenaventura 10

10/10/2017 Breast Cancer Awareness Month Workshop, Centers for Family Health (CMH) 16


10/11/2017 Breast Cancer Awareness Month Workshop, Housing Authority of the City of San Buenaventura 12

10/12/2017 Breast Cancer Awareness Month Workshop, Among Friends ADHC Center, Oxnard 28


10/18/2017 Migrant Ed Meeting, Oxnard Union High School District 33 10/19/2017 GCHP Informational Booth - Healthy Living, Mexican Consulate,

Oxnard 9

TOTAL PARTICIPANTS: 128

Cultural and Linguistic Services GCHP Health Education Department, Cultural Linguistic Services coordinates interpreting and translation services for members. GCHP offers interpreting services at no cost and in over 200 languages, including sign language. GCHP monitors requests for interpreting and translation services daily. Below are the totals for the month of October:


Sponsorship Program

The GCHP Sponsorship Program approved $1000 to North Oxnard Warriors Youth Football during the month of October. Note: all future sponsorship requests are on hold at this time.

Agency/Organization Approved Award Amount Event/Org Summary

North Oxnard Warriors Youth Football

$1000 This football/cheer program aims to provide safe, supervised sports activities for the underserved local youth community by sponsoring families to help with dues, field fees, uniforms/equipment and an end of year banquet with trophies for the teams. The program has seven football teams ranging in age from 6 to 14, and a cheer squad of 18 that range in age from as young as 4 years of age to 14 year old kids.

In-Person InterpreterServices

Sign LanguageInterpreter Services

TelephonicInterpreter Services

Total Requests 18 61 244

0

50

100

150

200

250

300

Language Access ServicesOctober 2017


PALLIATIVE CARE UPDATE SUMMARY Gold Coast Health Plan (GCHP) will implement a new Palliative Care Benefit effective January 1, 2018 in accordance to Senate Bill 1004 and APL 17-015. BACKGROUND The goal of palliative care is to help people with a serious illness cope with medical, emotional, social and spiritual challenges they may be facing. It improves the quality of life and reduces utilization of inpatient and emergency room services. Patients can remain under the care of their regular doctor and still receive treatment for their disease. In an effort to focus on patient choice and optimize quality of life, GCHP is working to strengthen the Palliative Care Benefit for members suffering from severe congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), liver disease, and advanced cancer with a life expectancy of 6 months or less. GCHP is striving to build a strong provider network of qualified, multidisciplinary teams dedicated to provide patient and family-centered care that address the physical, intellectual, emotional, social, and spiritual needs of our vulnerable population in the most compassionate way possible. DISCUSSION GCHP continues to actively engage the palliative care community in the development of the Program. Implementation strategies include the development of outreach and education efforts that address the specific needs of our palliative care population, including customized materials to recognize the various belief, values, and customs of our members. GCHP is actively collaborating with community-based organizations and external coalitions to align efforts towards promoting patient choice to optimize quality of life for our members. Currently, outreach efforts to promote palliative care awareness and share resources available to our provider network are being developed. Accordingly, GCHP continues to offer provider opportunities to enhance workforce development, including CME and certification trainings through the California State University Program. Additionally, GCHP will be developing a data collection system to monitor and collect palliative care enrollment and utilization data as required by APL 17-015. With the development of this data system, GCHP will be able to analyze the health status of this population and determine strategic interventions as needed.


Care Model of SB 1004 Medi-Cal Palliative Care:

(National Coalition for Hospice and Palliative Care, 2016)

The following illustrations are results from the Partners in Care: Palliative Care Program (PIPC) referenced by DHCS as implementation models. Based on these two methods of financial analysis, approximately $3 of hospital costs were avoided for each $1 spent on all costs associated with the PIPC pilot:

Total Costs of Care in the Last Six Months of Life:

(Partnership HealthPlan of California, 2015)


Costs Per Month, Before and After Palliative Care Pilot Enrollment

(Partnership HealthPlan of California, 2015)


PHARMACY BENEFIT PERFORMANCE AND TRENDS SUMMARY: Pharmacy utilization data is compiled from multiple sources including the pharmacy benefits manager (PBM) monthly reports, GCHP’s ASO operational membership counts, and invoice data. The data shown is through the end of September 2017. Although minor changes may occur to the data going forward due to the potential of claim adjustments from audits and/or member reimbursement requests, the data is generally considered complete due to point of sale processing of pharmacy data. GCHP has seen a slight membership drop in 2017. Slight cost declines occurred in November and December 2016, however costs increased again in January, March, May and with the new PBM contract as of June 2017. It is important to note that the data for June, July and August is inaccurate due to drug rate set-up errors. Additional information regarding the errors will be provided verbally. Hepatitis C continues to be a major driver of pharmacy costs though cost has decreased since the peak in May 2016. Formulary changes and the implementation of preferred products to align with DHCS kick payment utilization and cost assumptions have resulted in the Plan estimating to recoup all costs related to Hepatitis C from March 2017 through May 2017. A new hepatitis C drug was released with a much lower cost than all available agents. Due to this drug, the DHCS kickpayment is greatly reduced for FY 17-18. In response to this, GCHP has aligned its formulary status of hepatitis C agents with the DHCS usage assumption. In September, costs and reimbursement from DHCS are back in alignment. Abbreviation Key: PMPM: Per member per month PUPM: Per utilizer per month GDR: Generic dispensing rate PA: Prior authorization


PHARMACY COST TRENDS:

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

$-

$10.00

$20.00

$30.00

$40.00

$50.00

$60.00

$70.00

PMPM vs. Utilizing Percent

PMPM Utilizing Percent

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

Total Claims vs. GDR

Total Claims GDR


0

10,000

20,000

30,000

40,000

50,000

60,000

$-

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

Total Cost vs. Utilizing Members

Total Cost (in thousands) Utilizing Members

0

50,000

100,000

150,000

200,000

250,000

$-

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

PBM Administration Fees vs. Total Membership

Admin Fee PAs Total Membership


HEPATITIS C FOCUS:

PAID PER PERSCRIPTION:

$-

$50

$100

$150

$200

$250

$300

$350

$400

$450

$500

PMPM and PUPM

PMPM PMPM (wo Hep C)PUPM PUPM (wo Hep C)

$-

$100

$200

$300

$400

$500

$600

$700

$800

Dollars Paid Per Prescriptions

Paid/Rx Paid/Generic Rx Paid/Brand Rx

$-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

Costs vs. Expected Kick-Payment (costs in thoudsands)

Hep C Payments Hep C Costs


IMPLEMENTATION OF NEW PBM: OPTUMRX SUMMARY: Gold Coast Health Plan (GCHP or the Plan) contracts with a Pharmacy Benefits Manager (PBM) in order to provide pharmacy benefit services to its members. The commission entered into a new contract with OptumRx (ORx) to be the PBM effective June 1, 2017. BACKGROUND: GCHP worked diligently with ORx on plan specifications to build out GHCP’s pharmacy benefit within ORx’s systems. This has been a detailed, complex and arduous process to ensure that the benefit is built to the same specifications as with the prior PBM. DISCUSSION: ORx’s claim system went live for GCHP on June 1. At that time, GCHP and ORx conducted daily check-in calls to verify reports of identify issues and ensure that the benefit and systems were working properly. Through September 30, OptumRx has paid over 500,000 prescriptions claims for GCHP members. There are several outstanding issues and verbal updates will be provided on the following items:

• Kaiser pharmacies • 340B eligible drugs claims • Pharmacy reimbursement

Additionally, the commission directed OptumRx meet with pharmacy owners, pharmacists and their Pharmacy Services Administrative Organizations. Experience and notes from these meetings will be provided verbally.


Base Compensation Program

December 2017

AGENDA ITEM NO. 18


POLICY DELINEATION OF AUTHORITY

1. Any actions not specified as being the responsibility of the Commission are delegated to the CEO including, but not limited to:

• Management will develop a salary range schedule for each established position. While the schedule is not subject to Commission approval, it will be presented to the Commission on an annual basis as an information item.

Amended: November 28, 2011


Steve Smith, Director of Client SolutionsLTC Performance Strategies, Inc.

Phone:Office - 661.294.2929 ext. 10

Email:[email protected]

Website:www.ltcperformance.com

LinkedIn Profile:http://www.linkedin.com/pub/steve-smith/1a/300/117

Subscribe to LTC Monthly E-News: www.ltcperformance.com/register-enews.html

Steve Smith serves as LTC Performance’s Director of Client Solutions. Since joining LTC in 2009, Steve has consulted on hundreds of compensation initiatives. These initiatives include the design, development, and implementation of:

• Executive Compensation Programs

o Executive Base Pay

o Management Incentive Plans

o Stock & Phantom Equity Plans

o Cash-Based Long-Term Incentive Plans

o Executive Deferral Programs

• Sales Compensation Plans

• Company-wide Goals sharing Incentive Programs

• Salary Management Plans

Steve’s passion is working closely with clients to develop solutions that allow them to utilize their Total Compensation Program to attract & retain top caliber talent, while realizing a solid return on investment. Steve strives to ensure clients’ plans achieve a strong pay-for-performance relationship, while being externally competitive & internally equitable.

Steve holds a Master’s Degree in Business Administration (MBA) from Woodbury University and a Bachelor’s Degree in Business Administration/ Law from California State University, Northridge.

Steve Smith, MBALTC Performance Strategies, Inc. is a 25-year old Los Angeles-based “boutique”organization specializing in Total Compensation & Performance Development. Serving hundreds of prominent public and private company brand leaders, across industry, the LTC Consulting team delivers exceptional value by providing timely, cost-effective and practical solutions that serve to attract, motivate and retain talented performers, while yielding a strong Return on Investment (ROI).


mailto:[email protected]

http://www.ltcperformance.com/

http://www.linkedin.com/pub/steve-smith/1a/300/117

http://www.ltcperformance.com/register-enews.html

Total Rewards

Compensation Benefits

Career Development Culture


Goal• To ensure the base compensation component of the total

rewards program at Gold Coast:• Effectively provides market competitive, internally equitable base

compensation opportunities, in line with Gold Coast’s compensation positioning philosophy.


Actions Taken• Created simple compensation philosophy and set of target

objectives• Developed extensive survey market data for comparable roles

in the external market• Reviewed all job descriptions and employee compensation

levels within those job titles• Developed position leveling matrix to visually convey

hierarchical pay relationships by department• Developed pay structure• Developed a simple tool for effective utilization of each pay

range• Created Compensation Guide for Supervisors


Philosophy/Target ObjectivesPHILOSOPHY:• Gold Coast Health Plan strives to provide competitive, market-based, total compensation opportunities,

which are aligned with organizational and individual performance.

OBJECTIVES:• Attract and retain high caliber, well-suited individuals• Target internal base compensation pay grades near the 60th percentile of the relevant external market,

while providing an appropriate pay range for each role to allow for variances based on incumbent background, skills & proficiency

• Strengthen the relationship between pay & performance• Be externally competitive, internally equitable, and consistent in program administration• Ensure roles are clear, yet flexible• Ensure titles reflect roles and are positively perceived• Identify/ build/ strengthen critical organizational competencies • Provide opportunities for appropriate development and meaningful contribution• Comply with applicable legislation • Ensure the program is flexible to adapt to changing business and organizational circumstances• Ensure the program is simple to administer and easy to understand• Ensure the program is cost effective and provides a solid return on investment (ROI)


Benchmarking• Survey data was drawn from 3 reputable survey sources • This data was tailored for the unique size, location and industry of Gold

Coast.• Job descriptions were reviewed and roles were clarified with managers• Each role was then matched to an appropriate survey title in order to

assess external market pay levels


Position Leveling Process• A position leveling matrix, such as the one below, was developed for each functional area

• The leveling process takes into account external market data, internal reporting relationships/ equity, andcareer pathing considerations

Position Leveling Matrix Member Services

EXEMPT

PB 27 PB 28 PB 29 PB 30 PB 31 PB 32

PB 21 PB 22 PB 23 PB 24 PB 25 PB 26 Manager, Member Services

PB 15 PB 16 PB 17 PB 18 PB 19 PB 20 Sr. Auditor, Member Services

NONEXEMPT

PB 7 PB 8 PB 9 PB 10 PB 11

PB 3 PB 4 PB 5 PB 6 Representative, Member Services Auditor, Member Services I

Specialist, Member Services Auditor, Member Services II


Pay Structure• Once all the roles were leveled,

a pay structure was developed• The structures contain the min,

mid & max of each pay band• The mid-point of each band

generally correlates with thetargeted 60th percentile of theexternal market for the positionscontained within that band

• Bands are narrow enough toensure ranges closely correlatewith the market, while beingbroad enough to minimizeinternal disagreementsregarding leveling relationships


Utilization of the Pay Bands• The following graph illustrates the proposed usage of the pay bands• This tool assists all managers in understanding where a given employee should

ideally fit within their respective pay band, based upon their given level of proficiency, such that everyone is “calibrated” equally.


Questions, Anyone?

• Thank you for your time and attention• What questions come to mind?


AGENDA ITEM NO. 19 TO: Ventura County Medi-Cal Managed Care Commission FROM: Ted Bagley, Interim Chief Diversity Officer DATE: December 4, 2017 SUBJECT: Interim Chief Diversity Officer Update

INITIAL UPDATE:

COMPLETED COMPLIANCE TRAINING

Completed all current required Compliance training with certificate signed and verified through the compliance department.

MEETING Attended all managers meeting and all employee meetings with the intent of establishing a vision and diversity direction for the organization. INTERNAL CURRENT STATE MEETINGS In the process of establishing “current state” meetings with the chiefs and their designated leaders to establish trust, cooperation, and candor during investigations. VISION In order to establish a Diversity environment, trust and respect of the position has to be established. In the current state of available hours, the business is relegated to a defensive and reactionary posture verses an offensive proactive/aggressive approach. PRIOR PREPARATION PREVENTS POOR PERFORMANCE


Documents

Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba …€¦ · · 2017-12-01Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP)